Provider Demographics
NPI:1629209580
Name:SURESH, VIJAYARANI (NP)
Entity Type:Individual
Prefix:
First Name:VIJAYARANI
Middle Name:
Last Name:SURESH
Suffix:
Gender:F
Credentials:NP
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 9746
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5040
Mailing Address - Country:US
Mailing Address - Phone:207-791-3888
Mailing Address - Fax:207-828-7850
Practice Address - Street 1:6 FARLEY RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2642
Practice Address - Country:US
Practice Address - Phone:207-725-8079
Practice Address - Fax:207-798-4455
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP91025363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME001353703Medicare PIN