Basic Information
| Provider Information | |||||||||
| NPI: | 1013562685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIECHMAN | ||||||||
| FirstName: | MICRALYN | ||||||||
| MiddleName: | DENEE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN, FNP-C, ENP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25A JUNE ST | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040732642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074907900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25A JUNE ST | ||||||||
| Address2: | |||||||||
| City: | SANFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040732642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074907900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2019 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP141132 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | CNP211033 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP141132 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1013562685 | 05 | TX | MEDICAID |