Basic Information
Provider Information | |||||||||
NPI: | 1689177867 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GRISSOM | ||||||||
FirstName: | AMBER | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DNP, AGNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PRICE | ||||||||
OtherFirstName: | AMBER | ||||||||
OtherMiddleName: | NICOLE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DNP, AGNP-C | ||||||||
OtherLastNameType: | 1 | ||||||||
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: | 302 HUSSON AVE STE 1 | ||||||||
Address2: |   | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 044013373 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079476141 | ||||||||
FaxNumber: | 2079476720 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/14/2018 | ||||||||
LastUpdateDate: | 11/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | CNP201287 | ME | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.