Provider Demographics
NPI:1245500420
Name:CARPENTER, SALLY (NP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ONE MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005
Mailing Address - Country:US
Mailing Address - Phone:207-282-9080
Mailing Address - Fax:207-282-6099
Practice Address - Street 1:30 WEST COLE ROAD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005
Practice Address - Country:US
Practice Address - Phone:207-282-3349
Practice Address - Fax:207-282-6099
Is Sole Proprietor?:No
Enumeration Date:2012-01-05
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008703363LA2200X
MECNP121104363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1245500420Medicaid
ME1245500420Medicaid