Basic Information
| Provider Information | |||||||||
| NPI: | 1366488892 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARRIS | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 43 WHITING HILL RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079735035 | ||||||||
| FaxNumber: | 2079735042 | ||||||||
| Practice Location | |||||||||
| Address1: | 489 STATE ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079737000 | ||||||||
| FaxNumber: | 2079737394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 04/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | R032905 | ME | N | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant | 363LF0000X | AP081584 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 010507276 | 01 | ME | TAX ID | OTHER | 247850099 | 05 | ME | MEDICAID | 100544 | 01 | ME | ANTHEM | OTHER |