Healthcare Provider Details

I. General information

NPI: 1962023630
Provider Name (Legal Business Name): AMY E ROUSSEAU FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2020
Last Update Date: 05/04/2020
Certification Date: 05/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 CAMPUS AVE STE 214
LEWISTON ME ME
04240-6019
US

IV. Provider business mailing address

PO BOX 7291
LEWISTON ME
04243-7291
US

V. Phone/Fax

Practice location:
  • Phone: 207-330-3950
  • Fax: 207-330-3955
Mailing address:
  • Phone: 207-777-8950
  • Fax: 207-777-8800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP201017
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: