Provider Demographics
NPI:1124204375
Name:MACDONALD, GENEVIEVE R (ACNP)
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:R
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:301C US ROUTE ONE
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:818 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3112
Practice Address - Country:US
Practice Address - Phone:207-773-8161
Practice Address - Fax:207-773-1489
Is Sole Proprietor?:No
Enumeration Date:2008-01-18
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP111021363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002505602Medicare PIN
MEP01078554Medicare PIN