Provider Demographics
NPI:1376872606
Name:GANNAWAY, TAMMY L (FNP)
Entity Type:Individual
Prefix:
First Name:TAMMY
Middle Name:L
Last Name:GANNAWAY
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:PO BOX 2621
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04903-2621
Mailing Address - Country:US
Mailing Address - Phone:207-272-0638
Mailing Address - Fax:
Practice Address - Street 1:37 PARK ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7195
Practice Address - Country:US
Practice Address - Phone:207-333-1080
Practice Address - Fax:207-777-4649
Is Sole Proprietor?:No
Enumeration Date:2009-12-16
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001615363LF0000X
MECNP91069363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVAPRN001615OtherNV APRN
MECNP91069OtherME APRN
ME435223099Medicaid
ME1475901OtherMEDICARE B