Healthcare Provider Details

I. General information

NPI: 1003484767
Provider Name (Legal Business Name): MARIE LYNN CUPO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5104
  • Fax:
Mailing address:
  • Phone: 603-650-5104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number084702-21
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number08470223
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: