Provider Demographics
NPI:1700972445
Name:TETREAULT, DEBORAH R (WHNP)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:R
Last Name:TETREAULT
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SO. PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:272 CONGRESS ST.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101
Practice Address - Country:US
Practice Address - Phone:207-874-2466
Practice Address - Fax:207-774-4625
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER023566363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q03348Medicare UPIN
MEUX2074Medicare PIN
MENP4346Medicare PIN