Healthcare Provider Details

I. General information

NPI: 1740639210
Provider Name (Legal Business Name): LORRIE ANN PETTENGILL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 08/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 HOYT ST
SPRINGVALE ME
04083-1710
US

IV. Provider business mailing address

24 HOYT ST
SPRINGVALE ME
04083-1710
US

V. Phone/Fax

Practice location:
  • Phone: 207-730-0968
  • Fax: 207-850-1184
Mailing address:
  • Phone: 207-730-0968
  • Fax: 207-850-1184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: