Provider Demographics
NPI:1982128500
Name:LAFFELY, BRENTEN
Entity type:Individual
Prefix:
First Name:BRENTEN
Middle Name:
Last Name:LAFFELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CAMILLE DR
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ME
Mailing Address - Zip Code:04250-6028
Mailing Address - Country:US
Mailing Address - Phone:207-751-0239
Mailing Address - Fax:
Practice Address - Street 1:35 ELM ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2422
Practice Address - Country:US
Practice Address - Phone:207-729-1604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPI45608390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program