Basic Information
| Provider Information | |||||||||
| NPI: | 1447276886 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAYMOND | ||||||||
| FirstName: | DIANNE | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PMH-NP, DSN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PELLETIER | ||||||||
| OtherFirstName: | DIANNE | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 569 | ||||||||
| Address2: | |||||||||
| City: | RANGELEY | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049700569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078642699 | ||||||||
| FaxNumber: | 2078642969 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 CLEMENT WAY | ||||||||
| Address2: | |||||||||
| City: | BELGRADE | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049174370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074953323 | ||||||||
| FaxNumber: | 2074953353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2006 | ||||||||
| LastUpdateDate: | 04/14/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | R025851 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 163WP0809X | AP081135 | ME | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
ID Information
| ID | Type | State | Issuer | Description | 432406999 | 05 | ME | MEDICAID |