Basic Information
| Provider Information | |||||||||
| NPI: | 1942491188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PRUNIER | ||||||||
| FirstName: | KASEY | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VIOLETTE | ||||||||
| OtherFirstName: | KASEY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 78 ATLANTIC PL | ||||||||
| Address2: | |||||||||
| City: | SOUTH PORTLAND | ||||||||
| State: | ME | ||||||||
| PostalCode: | 041062316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076616654 | ||||||||
| FaxNumber: | 2078427773 | ||||||||
| Practice Location | |||||||||
| Address1: | 123 ANDOVER RD | ||||||||
| Address2: | |||||||||
| City: | WESTBROOK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040923848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2077612200 | ||||||||
| FaxNumber: | 2077612108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2007 | ||||||||
| LastUpdateDate: | 10/25/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1102 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.