Provider Demographics
NPI:1427034396
Name:DESALLE, MARY (GNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DESALLE
Suffix:
Gender:F
Credentials:GNP
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 284
Mailing Address - Street 2:
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05302-0284
Mailing Address - Country:US
Mailing Address - Phone:207-784-2554
Mailing Address - Fax:207-777-5363
Practice Address - Street 1:655 MAIN ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1543
Practice Address - Country:US
Practice Address - Phone:207-602-3571
Practice Address - Fax:207-602-3573
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER026628363LG0600X
MEAP081312363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME100072OtherBCBS
ME304310001OtherCIGNA
ME1427034396Medicaid
ME2735452OtherAETNA
MEMN5036OtherHPHC
ME500017332OtherRR MEDICARE
ME2735452OtherAETNA
NP0685Medicare PIN
ME500017332OtherRR MEDICARE
MENP0685Medicare ID - Type Unspecified