Healthcare Provider Details

I. General information

NPI: 1578671871
Provider Name (Legal Business Name): MARY ALMA LAKE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 02/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WELLNESS WAY SUITE B
TOPSHAM ME
04086-1768
US

IV. Provider business mailing address

1 WELLNESS WAY SUITE B
TOPSHAM ME
04086-1768
US

V. Phone/Fax

Practice location:
  • Phone: 207-406-7667
  • Fax: 207-406-7601
Mailing address:
  • Phone: 207-406-7667
  • Fax: 207-406-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberR019912
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR019912
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: