Basic Information
Provider Information | |||||||||
NPI: | 1659343408 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHERRILL | ||||||||
FirstName: | INGRID | ||||||||
MiddleName: | M. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 68 CHAPMAN ST. | ||||||||
Address2: |   | ||||||||
City: | DAMARISCOTTA | ||||||||
State: | ME | ||||||||
PostalCode: | 04543 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2075636623 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 108 CENTRE ST | ||||||||
Address2: |   | ||||||||
City: | BATH | ||||||||
State: | ME | ||||||||
PostalCode: | 045302550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2073861800 | ||||||||
FaxNumber: | 2078611801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/06/2006 | ||||||||
LastUpdateDate: | 01/11/2018 | ||||||||
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 | 363A00000X | PA-552 | ME | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 611454199 | 01 |   | GROUP FEDERAL TAX ID | OTHER | 312480099 | 05 | ME |   | MEDICAID |