Provider Demographics
NPI:1366488892
Name:GARDNER, MICHELLE A (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:GARDNER
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:A
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:43 WHITING HILL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-1005
Mailing Address - Country:US
Mailing Address - Phone:207-973-5035
Mailing Address - Fax:207-973-5042
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-7000
Practice Address - Fax:207-973-7394
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER032905163WR0006X
MEAP081584363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010507276OtherTAX ID
ME247850099Medicaid
ME100544OtherANTHEM
ME010507276OtherTAX ID
MENP3522Medicare ID - Type Unspecified