Provider Demographics
NPI:1013562685
Name:WIECHMAN, MICRALYN DENEE (APRN, FNP-C, ENP-C)
Entity Type:Individual
Prefix:MS
First Name:MICRALYN
Middle Name:DENEE
Last Name:WIECHMAN
Suffix:
Gender:F
Credentials:APRN, FNP-C, ENP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25A JUNE ST
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04073-2642
Mailing Address - Country:US
Mailing Address - Phone:207-490-7900
Mailing Address - Fax:
Practice Address - Street 1:25A JUNE ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-2642
Practice Address - Country:US
Practice Address - Phone:207-490-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-09
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP141132363L00000X, 363LF0000X
MECNP211033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1013562685Medicaid