Provider Demographics
NPI:1043887375
Name:WING, THERESA ANN
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:WING
Suffix:
Gender:F
Credentials:
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 182
Mailing Address - Street 2:
Mailing Address - City:LISBON FALLS
Mailing Address - State:ME
Mailing Address - Zip Code:04252-0182
Mailing Address - Country:US
Mailing Address - Phone:207-754-0411
Mailing Address - Fax:
Practice Address - Street 1:18 MOLLISON WAY
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5811
Practice Address - Country:US
Practice Address - Phone:207-312-6860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN45167163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)