Provider Demographics
NPI:1811512668
Name:WALTON, MARY JANE (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:WALTON
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 1:529 S PATTEN RD
Mailing Address - Street 2:
Mailing Address - City:PATTEN
Mailing Address - State:ME
Mailing Address - Zip Code:04765-3007
Mailing Address - Country:US
Mailing Address - Phone:207-538-3700
Mailing Address - Fax:207-528-2595
Practice Address - Street 1:59 BANGOR ST
Practice Address - Street 2:
Practice Address - City:HOULTON
Practice Address - State:ME
Practice Address - Zip Code:04730-1740
Practice Address - Country:US
Practice Address - Phone:207-538-3700
Practice Address - Fax:207-528-2595
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP201051363LF0000X
MERN53734163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily