Healthcare Provider Details

I. General information

NPI: 1265067789
Provider Name (Legal Business Name): DONNA MARIE HEDBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 SAGAMORE AVE
PORTSMOUTH NH
03801-5585
US

IV. Provider business mailing address

1145 SAGAMORE AVE
PORTSMOUTH NH
03801-5503
US

V. Phone/Fax

Practice location:
  • Phone: 603-433-5075
  • Fax:
Mailing address:
  • Phone: 603-431-6703
  • Fax: 603-430-3753

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number03146-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: