Healthcare Provider Details

I. General information

NPI: 1356347900
Provider Name (Legal Business Name): JEAN MARIE ANTONUCCI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 11/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MT BLUE CIR STE 2
FARMINGTON ME
04938-6239
US

IV. Provider business mailing address

115 MT BLUE CIR STE 2
FARMINGTON ME
04938-6239
US

V. Phone/Fax

Practice location:
  • Phone: 207-778-3313
  • Fax: 207-778-3544
Mailing address:
  • Phone: 207-778-3313
  • Fax: 207-778-3544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12782
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: