Healthcare Provider Details

I. General information

NPI: 1699502302
Provider Name (Legal Business Name): CARRIE JOY CRECELIUS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE JOY WEBB RN

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FODEN RD STE 303
SOUTH PORTLAND ME
04106-2327
US

IV. Provider business mailing address

100 GANNETT DR STE C
SOUTH PORTLAND ME
04106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 207-523-3767
  • Fax:
Mailing address:
  • Phone: 207-347-2947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN64184
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: