Provider Demographics
NPI:1760927792
Name:THERAPIA - MARY PENNER, PC
Entity Type:Organization
Organization Name:THERAPIA - MARY PENNER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNER
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:207-844-2045
Mailing Address - Street 1:12 INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-7314
Mailing Address - Country:US
Mailing Address - Phone:207-844-2045
Mailing Address - Fax:204-837-6951
Practice Address - Street 1:12 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-7314
Practice Address - Country:US
Practice Address - Phone:207-844-2045
Practice Address - Fax:204-837-6951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP091053313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility