Healthcare Provider Details

I. General information

NPI: 1699716928
Provider Name (Legal Business Name): MARY E THERRIAULT N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 STATE ST
BANGOR ME
04401-5610
US

IV. Provider business mailing address

67 CLARK HILL RD
EAST HOLDEN ME
04429-7248
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-6508
  • Fax: 207-941-8342
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberCNP81724
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: