Basic Information
Provider Information | |||||||||
NPI: | 1356476436 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GROVER | ||||||||
FirstName: | NANCY | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PMHNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOGAN | ||||||||
OtherFirstName: | NANCY | ||||||||
OtherMiddleName: | J. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 47 KENNEBEC RD | ||||||||
Address2: |   | ||||||||
City: | HAMPDEN | ||||||||
State: | ME | ||||||||
PostalCode: | 044441315 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2078622136 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 42 CEDAR STREET | ||||||||
Address2: |   | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 044020425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079470366 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/22/2007 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
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 | 026543 | ME | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | P00039153 | 01 | ME | RAILROAD MEDICARE | OTHER |