Healthcare Provider Details

I. General information

NPI: 1033170709
Provider Name (Legal Business Name): MELISSA NYE LIBBY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2006
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BRICKHILL AVE STE 304
SOUTH PORTLAND ME
04106-1999
US

IV. Provider business mailing address

100 BRICKHILL AVE STE 304
SOUTH PORTLAND ME
04106-1999
US

V. Phone/Fax

Practice location:
  • Phone: 207-761-4700
  • Fax: 207-467-8910
Mailing address:
  • Phone: 207-761-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number027766
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP081250
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP81250
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: