Provider Demographics
NPI:1417350901
Name:MELISSA N LIBBY FNP LLC
Entity Type:Organization
Organization Name:MELISSA N LIBBY FNP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:N
Authorized Official - Last Name:LIBBY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:207-761-4700
Mailing Address - Street 1:100 BRICKHILL AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1999
Mailing Address - Country:US
Mailing Address - Phone:207-761-4700
Mailing Address - Fax:207-761-4744
Practice Address - Street 1:100 BRICKHILL AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1999
Practice Address - Country:US
Practice Address - Phone:207-761-4700
Practice Address - Fax:207-761-4744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-29
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81250305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1417350901Medicaid
MEE100183559Medicare PIN