Healthcare Provider Details

I. General information

NPI: 1821635020
Provider Name (Legal Business Name): MARISSA P TARDIF FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 09/18/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 CAMPUS DR STE B
SCARBOROUGH ME
04074-7229
US

IV. Provider business mailing address

92 CAMPUS DR STE B
SCARBOROUGH ME
04074-7229
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-8810
  • Fax: 207-777-8155
Mailing address:
  • Phone: 207-885-4362
  • Fax: 207-883-1010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP191212
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: