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General NPI Number Information
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NPI Number | 1902415268
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Entity Type | Individual
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Provider Name | MICAH GORDON MALENFANT DNP, PMHNP-BC, RN
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Gender | Male
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Dates
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Enumeration Date | 07/23/2020
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Last Update Date | 09/24/2024
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Provider Practice Location Address
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Address Line | 15 PLEASANT HILL RD STE 204
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City | SCARBOROUGH
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State | ME
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Zip | 04074-7678
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Country | US
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Telephone | 207-600-4025
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Fax | 207-600-9625
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Provider Business Mailing Address
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Address Line | 15 PLEASANT HILL RD STE 204
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City | SCARBOROUGH
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State | ME
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Zip | 04074-7678
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | CNP201195
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License Number State | ME
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