Healthcare Provider Details

I. General information

NPI: 1104707082
Provider Name (Legal Business Name): DANIELLE JANET MILOVANOVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WESTERN AVE
SOUTH PORTLAND ME
04106-1704
US

IV. Provider business mailing address

152 HOWITT RD
LYMAN ME
04002-6224
US

V. Phone/Fax

Practice location:
  • Phone: 207-114-7111
  • Fax: 207-775-1985
Mailing address:
  • Phone: 207-774-7111
  • Fax: 207-775-1985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberLPN13929
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: