Healthcare Provider Details

I. General information

NPI: 1124204375
Provider Name (Legal Business Name): GENEVIEVE R MACDONALD ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 CONGRESS ST
PORTLAND ME
04102-3112
US

IV. Provider business mailing address

301C US ROUTE ONE
SCARBOROUGH ME
04074-9701
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-8161
  • Fax: 207-773-1489
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCNP111021
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberCNP111021
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: