Healthcare Provider Details

I. General information

NPI: 1932202082
Provider Name (Legal Business Name): ELIZABETH ANN PAVAO FNP, RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-2934
  • Fax: 207-662-6389
Mailing address:
  • Phone: 207-662-2934
  • Fax: 207-662-6389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN45048
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number11680
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP81333
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: