Provider Demographics
NPI:1962854786
Name:BOUTIN, BRIANNA (NP)
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:
Last Name:BOUTIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:
Other - Last Name:MAURO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12 HIGH ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7676
Mailing Address - Country:US
Mailing Address - Phone:207-795-5730
Mailing Address - Fax:207-795-5749
Practice Address - Street 1:12 HIGH ST
Practice Address - Street 2:SUITE 301
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7676
Practice Address - Country:US
Practice Address - Phone:207-795-5730
Practice Address - Fax:207-795-5749
Is Sole Proprietor?:No
Enumeration Date:2016-07-05
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP161075363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner