Provider Demographics
NPI:1255580429
Name:WEBER, JESSICA H (ACNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:H
Last Name:WEBER
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:H
Other - Last Name:VAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ACNP
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:DEPT OF CARDIAC SERVICES
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-2414
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:DEPT OF CARDIAC SERVICES
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-12
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081946363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000829001Medicare PIN