Basic Information
| Provider Information | |||||||||
| NPI: | 1396868394 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 MILES ST. | ||||||||
| Address2: | MILES MED. GROUP - ANESTHESIA | ||||||||
| City: | DAMARISCOTTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075634511 | ||||||||
| FaxNumber: | 2075634103 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 MILES ST. | ||||||||
| Address2: | MILES MEDICAL GROUP | ||||||||
| City: | DAMARISCOTTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2075634511 | ||||||||
| FaxNumber: | 2075634103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 10/02/2008 | ||||||||
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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 | 367500000X | 44707 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | R044707 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 321630099 | 05 | ME | MEDICAID |