Healthcare Provider Details

I. General information

NPI: 1205447455
Provider Name (Legal Business Name): SHAWN THEBERGE APRN, FNP-C, NR-P
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W SUMMIT AVE
WALES WI
53183-9427
US

IV. Provider business mailing address

11 CANYON WAY
WINDHAM ME
04062-4895
US

V. Phone/Fax

Practice location:
  • Phone: 207-650-7540
  • Fax:
Mailing address:
  • Phone: 207-650-7540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP8036707
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN72498
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP201467
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: