Provider Demographics
NPI:1699716928
Name:THERRIAULT, MARY E (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:THERRIAULT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 CLARK HILL RD
Mailing Address - Street 2:
Mailing Address - City:EAST HOLDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04429-7248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:792 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5610
Practice Address - Country:US
Practice Address - Phone:207-947-6508
Practice Address - Fax:207-941-8342
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81724363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MENP1390Medicare ID - Type Unspecified