Healthcare Provider Details

I. General information

NPI: 1992281117
Provider Name (Legal Business Name): ASHLEY MAUREEN JOHNSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2018
Last Update Date: 08/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 MARGINAL WAY STE 700
PORTLAND ME
04101
US

IV. Provider business mailing address

100 GANNETT DR STE C
SOUTH PORTLAND ME
04106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-5816
  • Fax: 207-523-8597
Mailing address:
  • Phone: 207-828-0361
  • Fax: 207-874-1483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP181113
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: