Healthcare Provider Details

I. General information

NPI: 1558096255
Provider Name (Legal Business Name): CHRISTINA MARIE BOHURJAK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/18/2022
Certification Date: 07/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WESTERN AVE
SOUTH PORTLAND ME
04106-1704
US

IV. Provider business mailing address

30 WAINWRIGHT CIR E
SOUTH PORTLAND ME
04106-2519
US

V. Phone/Fax

Practice location:
  • Phone: 207-560-0436
  • Fax:
Mailing address:
  • Phone: 207-242-1351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN58582
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: