Provider Demographics
NPI:1720554611
Name:THERIAULT, LISA ANN (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:THERIAULT
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 1:6 CHETS MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:WEST GARDINER
Mailing Address - State:ME
Mailing Address - Zip Code:04345-3580
Mailing Address - Country:US
Mailing Address - Phone:207-724-3139
Mailing Address - Fax:
Practice Address - Street 1:7 HIGHWOOD ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-5739
Practice Address - Country:US
Practice Address - Phone:207-873-0705
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP181186363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily