Provider Demographics
NPI:1194937250
Name:MARY DELOIS,F.N.P.,LLC
Entity type:Organization
Organization Name:MARY DELOIS,F.N.P.,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:F.N.P.
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:DELOIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-761-4700
Mailing Address - Street 1:125 BANCROFT STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:260 WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-761-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER023829363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MER023829OtherNURDING LISCENCE
MEDENP1017Medicare ID - Type Unspecified