Provider Demographics
NPI:1407886443
Name:DOSTAL-JOHNSON, DORENE A (FNP)
Entity Type:Individual
Prefix:MRS
First Name:DORENE
Middle Name:A
Last Name:DOSTAL-JOHNSON
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 7291
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04243-7291
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 GRACELAWN RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-6334
Practice Address - Country:US
Practice Address - Phone:207-333-4799
Practice Address - Fax:207-333-4767
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81264363LF0000X
MEAP081264363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400311114Medicare PIN
MEE400311117Medicare PIN
ME047747OtherANTHEM
MEP62609Medicare UPIN
ME3752965OtherAETNA HMO
MEAA20123OtherHPHC
ME7077337OtherAETNA NON-HMO
ME163380000Medicaid
MENP3826Medicare ID - Type Unspecified