Provider Demographics
NPI:1356418685
Name:THEOBALD, MARY ELSA (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELSA
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:BROOKS
Mailing Address - State:ME
Mailing Address - Zip Code:04921-0159
Mailing Address - Country:US
Mailing Address - Phone:207-722-3488
Mailing Address - Fax:207-722-3183
Practice Address - Street 1:55 REYNOLDS ROAD
Practice Address - Street 2:
Practice Address - City:BROOKS
Practice Address - State:ME
Practice Address - Zip Code:04915
Practice Address - Country:US
Practice Address - Phone:207-722-3488
Practice Address - Fax:207-722-3183
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER030807363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEP23039Medicare UPIN