Basic Information
| Provider Information | |||||||||
| NPI: | 1699864504 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCINNIS | ||||||||
| FirstName: | MELINDA | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PLUNKETT | ||||||||
| OtherFirstName: | MELINDA | ||||||||
| OtherMiddleName: | S | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1599 | ||||||||
| Address2: | PENOBSCOT COMMUNITY HEALTH CENTER | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044021599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079455247 | ||||||||
| FaxNumber: | 2079470435 | ||||||||
| Practice Location | |||||||||
| Address1: | 735 WILSON STREET | ||||||||
| Address2: | PENOBSCOT COMMUNITY HEALTH CENTER/ EXTENDED CARE SERVIC | ||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079922601 | ||||||||
| FaxNumber: | 2079892280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CNP81598 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 432301999 | 05 | ME | MEDICAID |