Healthcare Provider Details

I. General information

NPI: 1437155884
Provider Name (Legal Business Name): CAROLYN K GOTHARD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 WILSON ST
BREWER ME
04412
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-945-5247
  • Fax: 207-990-1248
Mailing address:
  • Phone: 207-945-5247
  • Fax: 207-947-0435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP081480
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRO35933
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: