Healthcare Provider Details

I. General information

NPI: 1285759993
Provider Name (Legal Business Name): LISA BELANGER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 05/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 COLLEGE AVE 125 UPTON HALL
GORHAM ME
04038-1032
US

IV. Provider business mailing address

11 LISAS WAY
NORTH YARMOUTH ME
04097-6075
US

V. Phone/Fax

Practice location:
  • Phone: 207-780-5411
  • Fax:
Mailing address:
  • Phone: 207-657-2299
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR021136
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP81142
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier305647
Identifier TypeOTHER
Identifier StateME
Identifier IssuerAETNA
# 2
Identifier39362
Identifier TypeOTHER
Identifier StateME
Identifier IssuerHARVARD PILGRIM
# 3
IdentifierM2048203
Identifier TypeOTHER
Identifier StateME
Identifier IssuerCIGNA
# 4
Identifier324760099
Identifier TypeMEDICAID
Identifier StateME
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: