Basic Information
| Provider Information | |||||||||
| NPI: | 1447480264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLANCHETTE | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOURNIER | ||||||||
| OtherFirstName: | LAUREN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 149 MAIN ST | ||||||||
| Address2: | STE 2A | ||||||||
| City: | WINTHROP | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043641486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076243800 | ||||||||
| FaxNumber: | 2076243845 | ||||||||
| Practice Location | |||||||||
| Address1: | 149 MAIN ST | ||||||||
| Address2: | STE 2A | ||||||||
| City: | WINTHROP | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043641486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076243800 | ||||||||
| FaxNumber: | 2076243845 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2009 | ||||||||
| LastUpdateDate: | 12/12/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA001175 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1447480264 | 05 | ME | MEDICAID |