Provider Demographics
NPI:1629510821
Name:BANASZEK, MARY ELLEN (RN)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:BANASZEK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:ELLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:124 LANCASTER RD
Mailing Address - Street 2:
Mailing Address - City:CANAAN
Mailing Address - State:ME
Mailing Address - Zip Code:04924-3136
Mailing Address - Country:US
Mailing Address - Phone:207-561-0626
Mailing Address - Fax:
Practice Address - Street 1:124 LANCASTER RD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:ME
Practice Address - Zip Code:04924-3136
Practice Address - Country:US
Practice Address - Phone:207-561-0626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-06
Last Update Date:2016-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN22588163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse