Healthcare Provider Details

I. General information

NPI: 1609304658
Provider Name (Legal Business Name): JESSICA B MCCONVILLE F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 VERANDA ST
PORTLAND ME
04103-5545
US

IV. Provider business mailing address

PO BOX 9746
PORTLAND ME
04104-5040
US

V. Phone/Fax

Practice location:
  • Phone: 207-828-2402
  • Fax: 207-828-2425
Mailing address:
  • Phone: 207-791-3888
  • Fax: 207-828-7850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP171064
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: