Healthcare Provider Details

I. General information

NPI: 1114687480
Provider Name (Legal Business Name): AMIE FAGAN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 NORTH ST
WATERVILLE ME
04901-4974
US

IV. Provider business mailing address

149 NORTH ST
WATERVILLE ME
04901-4974
US

V. Phone/Fax

Practice location:
  • Phone: 207-873-1098
  • Fax: 207-861-5461
Mailing address:
  • Phone: 207-873-1098
  • Fax: 207-861-5461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP211610
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: