Healthcare Provider Details

I. General information

NPI: 1639571227
Provider Name (Legal Business Name): NICOLE NELSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 BROADWAY
BANGOR ME
04401-3979
US

IV. Provider business mailing address

C/O ST MARYS HEALTH SYSTEM - PROVIDER ENROLLMENT PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-907-1430
  • Fax: 207-907-3508
Mailing address:
  • Phone: 207-777-8560
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.012256
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRNA173045
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: