Individual
MARY DESALLE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
GNP
Contact information
Practice address
655 MAIN ST, SACO, ME 04072-1543
(207) 602-3571
(207) 602-3573
Mailing address
PO BOX 284, BRATTLEBORO, VT 05302-0284
(207) 784-2554
(207) 777-5363
Taxonomy
Speciality
Code
Description
License number
State
363LG0600X
Gerontology Nurse Practitioner
Primary
AP081312
ME
363LG0600X
Gerontology Nurse Practitioner
R026628
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
100072
BCBS
ME
05
—
1427034396
—
ME
01
—
2735452
AETNA
ME
01
—
304310001
CIGNA
ME
01
—
500017332
RR MEDICARE
ME
01
—
MN5036
HPHC
ME
Enumeration date
12/21/2005
Last updated
02/05/2013
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