Provider Demographics
NPI:1073756821
Name:TKACZYK, ANN GIRLIE RIVERA (NP-C)
Entity Type:Individual
Prefix:
First Name:ANN GIRLIE
Middle Name:RIVERA
Last Name:TKACZYK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:C/O ST MARY'S HEALTH SYSTEM - PROVIDER ENROLLMENT
Mailing Address - Street 2:PO BOX 7291
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:207-777-8695
Mailing Address - Fax:207-777-8800
Practice Address - Street 1:173 DANIEL WEBSTER HWY
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-5256
Practice Address - Country:US
Practice Address - Phone:603-891-4500
Practice Address - Fax:603-891-4414
Is Sole Proprietor?:No
Enumeration Date:2009-04-09
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN225861363LF0000X
NH040723-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3075218Medicaid