1811451545 NPI number — MISS MONICA MARIE LEAVITT

Table of content: MISS MONICA MARIE LEAVITT (NPI 1811451545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811451545 NPI number — MISS MONICA MARIE LEAVITT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEAVITT
Provider First Name:
MONICA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MISS
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:
1811451545
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2 MAPLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARDINER
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04345-2022
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARDINER
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04345-2022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-504-2517
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/28/2019

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: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000000000000000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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