Healthcare Provider Details

I. General information

NPI: 1912167347
Provider Name (Legal Business Name): LAURA B SMITH-TUCKER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 MEDICAL CENTER DR SUITE 3400
BRUNSWICK ME
04011-2653
US

IV. Provider business mailing address

121 MEDICAL CENTER DR SUITE 3400
BRUNSWICK ME
04011-2653
US

V. Phone/Fax

Practice location:
  • Phone: 207-406-7300
  • Fax: 207-406-7301
Mailing address:
  • Phone: 207-406-7300
  • Fax: 207-406-7301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberR052972
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR052972
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: