Healthcare Provider Details

I. General information

NPI: 1629510821
Provider Name (Legal Business Name): MARY ELLEN BANASZEK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY ELLEN ELLIS RN

II. Dates (important events)

Enumeration Date: 11/06/2016
Last Update Date: 11/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 LANCASTER RD
CANAAN ME
04924-3136
US

IV. Provider business mailing address

124 LANCASTER RD
CANAAN ME
04924-3136
US

V. Phone/Fax

Practice location:
  • Phone: 207-561-0626
  • Fax:
Mailing address:
  • Phone: 207-561-0626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN22588
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: