=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962437152
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LILLIAN R MANDL APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2006
-----------------------------------------------------
Last Update Date | 06/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | MAINE COMPREHENSIVE PAIN MANAGEMENT, P.C. 400 ENTERPRISE DRIVE, SUITE 1
-----------------------------------------------------
City | SCARBOROUGH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04074-7663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-289-6726
-----------------------------------------------------
Fax | 207-289-1219
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | MAINE COMPREHENSIVE PAIN MANAGEMENT, P.C. 400 ENTERPRISE DRIVE, SUITE 1
-----------------------------------------------------
City | SCARBOROUGH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04074-7663
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-289-6726
-----------------------------------------------------
Fax | 207-289-1219
-----------------------------------------------------
=====================================================
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 | 03067523
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | MM3521742
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------