Healthcare Provider Details

I. General information

NPI: 1669423349
Provider Name (Legal Business Name): DIANA VANDERMAST FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DIANA M HAYDEN FNP

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 HALEY CT
SANGERVILLE ME
04479-3000
US

IV. Provider business mailing address

PO BOX 1129
GREENVILLE ME
04441-1129
US

V. Phone/Fax

Practice location:
  • Phone: 207-876-4811
  • Fax: 207-695-2329
Mailing address:
  • Phone: 207-695-5215
  • Fax: 207-695-2329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR048203
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: