Basic Information
| Provider Information | |||||||||
| NPI: | 1063074425 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEBO | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | LAUREN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43 WHITING HILL RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079735000 | ||||||||
| FaxNumber: | 2079735042 | ||||||||
| Practice Location | |||||||||
| Address1: | 885 UNION ST STE 145 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044013073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079739595 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2019 | ||||||||
| LastUpdateDate: | 09/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | MD24001 | ME | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.