Provider Demographics
NPI:1922375864
Name:BOTLER, MEGHAN E (ACNP)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:E
Last Name:BOTLER
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2414
Practice Address - Fax:207-662-6038
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009250363LA2100X
MECNP161031363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400334223Medicare PIN