Provider Demographics
NPI:1780648246
Name:SHEA, MARY (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SHEA
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 1:1795 HAMMOND ST
Mailing Address - Street 2:
Mailing Address - City:HERMON
Mailing Address - State:ME
Mailing Address - Zip Code:04401-1135
Mailing Address - Country:US
Mailing Address - Phone:207-992-2205
Mailing Address - Fax:
Practice Address - Street 1:86 DAVIS ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6410
Practice Address - Country:US
Practice Address - Phone:207-992-2205
Practice Address - Fax:207-992-2207
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER031280363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME5871218OtherAETNA
MER031280OtherTRICARE
MEMN5123OtherHARVARD PILGRIM
ME5871218OtherAETNA
MEMN5123OtherHARVARD PILGRIM