Provider Demographics
NPI:1083650204
Name:WILLETT, MIRANDA (RN)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:
Last Name:WILLETT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 MOUNT HOPE AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4096
Mailing Address - Country:US
Mailing Address - Phone:207-770-5457
Mailing Address - Fax:
Practice Address - Street 1:68 MOUNT HOPE AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4096
Practice Address - Country:US
Practice Address - Phone:207-770-5457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X
MERN65159163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No376K00000XNursing Service Related ProvidersNurse's Aide