Provider Demographics
NPI:1336100213
Name:BATES, JACQUELINE (FNP)
Entity type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:BATES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FODEN ROAD WEST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2327
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:259 MAIN ST
Practice Address - Street 2:YARMOUTH HEALTH CENTER
Practice Address - City:YARMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04096
Practice Address - Country:US
Practice Address - Phone:207-846-9013
Practice Address - Fax:207-523-8586
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME024691363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NP1882Medicare ID - Type Unspecified
S83637Medicare UPIN
MEVX0675Medicare PIN