Healthcare Provider Details

I. General information

NPI: 1922622026
Provider Name (Legal Business Name): JENNIFER LYNN GASAWAY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 WHITING HILL RD STE 21
BREWER ME
04412-1006
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-7478
  • Fax: 207-973-9463
Mailing address:
  • Phone: 207-973-7478
  • Fax: 207-973-9463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP201083
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: