Provider Demographics
NPI:1851480305
Name:DESMOND, JENNIFER S (FNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:DESMOND
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 1:15 MEDICAL CENTER LOOP
Mailing Address - Street 2:
Mailing Address - City:VINALHAVEN
Mailing Address - State:ME
Mailing Address - Zip Code:04863
Mailing Address - Country:US
Mailing Address - Phone:207-863-4341
Mailing Address - Fax:207-863-9358
Practice Address - Street 1:15 MEDICAL CENTER LOOP
Practice Address - Street 2:
Practice Address - City:VINALHAVEN
Practice Address - State:ME
Practice Address - Zip Code:04863
Practice Address - Country:US
Practice Address - Phone:207-863-4341
Practice Address - Fax:207-863-9358
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER052901363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432341699Medicaid