Provider Demographics
NPI:1669879680
Name:CROCKETT-MAILLET, GINNY (WHNP)
Entity type:Individual
Prefix:
First Name:GINNY
Middle Name:
Last Name:CROCKETT-MAILLET
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:GINNY
Other - Middle Name:
Other - Last Name:CROCKETT-MAILLET
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:WHNP
Mailing Address - Street 1:GENERAL DELIVERY
Mailing Address - Street 2:
Mailing Address - City:WISCASSET
Mailing Address - State:ME
Mailing Address - Zip Code:04578-9999
Mailing Address - Country:US
Mailing Address - Phone:970-420-1640
Mailing Address - Fax:
Practice Address - Street 1:195 FORE RIVER PKWY
Practice Address - Street 2:SUITE 360
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2780
Practice Address - Country:US
Practice Address - Phone:207-553-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME081878363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health