1205495793 NPI number — WELLNESS FOR WOMEN PLLC

Table of content: (NPI 1205495793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205495793 NPI number — WELLNESS FOR WOMEN PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLNESS FOR WOMEN PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1205495793
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/22/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
94C WHITTEN HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNEBUNKPORT
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04046-5114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-467-5588
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 PORTLAND RD STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEBUNK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04043-6789
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-502-7400
Provider Business Practice Location Address Fax Number:
207-569-0012
Provider Enumeration Date:
06/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
DRIES
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
207-467-5588

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 433002499 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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