Healthcare Provider Details

I. General information

NPI: 1700963071
Provider Name (Legal Business Name): GAIL M BOAZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

193 MAIN ST SUITE 9
NORWAY ME
04268
US

IV. Provider business mailing address

300 SOUTHBOROUGH DR SUITE 201
SOUTH PORTLAND ME
04106-6914
US

V. Phone/Fax

Practice location:
  • Phone: 207-743-8766
  • Fax: 207-743-1579
Mailing address:
  • Phone: 207-661-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP081039
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP30006925
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: