Provider Demographics
NPI:1265865323
Name:DEANE, JENNIFER K (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:DEANE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:1 HARNOIS AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-4392
Practice Address - Country:US
Practice Address - Phone:207-661-3400
Practice Address - Fax:207-661-3401
Is Sole Proprietor?:No
Enumeration Date:2013-08-13
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP131077363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400114557Medicare PIN
MEE400116962Medicare PIN
MEE400114950Medicare PIN