Provider Demographics
NPI:1164461307
Name:SMALL, BETTY BRICKER (ANP)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:BRICKER
Last Name:SMALL
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 SEWALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2624
Mailing Address - Country:US
Mailing Address - Phone:207-775-3526
Mailing Address - Fax:207-775-5658
Practice Address - Street 1:50 SEWALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2624
Practice Address - Country:US
Practice Address - Phone:207-775-3526
Practice Address - Fax:207-775-5658
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER035597363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEQ71347Medicare UPIN
MENP5419Medicare ID - Type Unspecified