Provider Demographics
NPI:1538245097
Name:THERIAULT, CHRISTINA ROSE (NP)
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:ROSE
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 587
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04332-0587
Mailing Address - Country:US
Mailing Address - Phone:207-509-3271
Mailing Address - Fax:207-660-4203
Practice Address - Street 1:139 MARKET ST
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1410
Practice Address - Country:US
Practice Address - Phone:207-402-3220
Practice Address - Fax:207-834-1188
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ME1538245097363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health