1154790814 NPI number — STACY MARISSA FARESE

Table of content: STACY MARISSA FARESE (NPI 1154790814)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154790814 NPI number — STACY MARISSA FARESE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FARESE
Provider First Name:
STACY
Provider Middle Name:
MARISSA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154790814
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 186
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WELLS
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04090-0186
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-370-2483
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 ALFRED ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIDDEFORD
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04005-3102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-216-2637
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  CC5472 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: Y10400 . This is a "MEDICARE PTAN Y10400" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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