Healthcare Provider Details

I. General information

NPI: 1003049768
Provider Name (Legal Business Name): NICOLE L. MIZNER C.P.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 CONGRESS ST SUITE 310
PORTLAND ME
04102-3100
US

IV. Provider business mailing address

887 CONGRESS ST SUITE 310
PORTLAND ME
04102-3100
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-2723
  • Fax: 207-773-3941
Mailing address:
  • Phone: 207-773-2723
  • Fax: 207-773-3941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP091039
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: