Provider Demographics
NPI:1043092307
Name:PELLETIER, RENEE (AGNP-C)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:PELLETIER
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1428
Mailing Address - Country:US
Mailing Address - Phone:207-834-6784
Mailing Address - Fax:
Practice Address - Street 1:197 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1409
Practice Address - Country:US
Practice Address - Phone:207-834-6784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-19
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP231569363LG0600X, 363LP2300X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care