=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790437143
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER DISSELL FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2022
-----------------------------------------------------
Last Update Date | 01/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 ENTERPRISE DR
-----------------------------------------------------
City | AUGUSTA
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04330-7997
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-621-8880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26 FULLER RD
-----------------------------------------------------
City | CUMBERLAND
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04021-3063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-462-7360
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | CNP201465
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------