Basic Information
| Provider Information | |||||||||
| NPI: | 1265957013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORGNATI | ||||||||
| FirstName: | MARYJANE | ||||||||
| MiddleName: | BAHIYYIH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PMHNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 173 MIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035843508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037885029 | ||||||||
| FaxNumber: | 6037885607 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 MIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035843556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037882521 | ||||||||
| FaxNumber: | 6037885092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2017 | ||||||||
| LastUpdateDate: | 02/18/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 064044-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 101YA0400X | 064044-23 | NH | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1031732 | 05 | VT | MEDICAID | 3110854 | 05 | NH | MEDICAID |