MEDICARE: KATHLEEN DISHNER, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R019254	OTHER	ME	LICENSE

General Provider Information

NPI Number	:	1639735715
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KATHLEEN DISHNER, INC

Provider Business Mailing Address
First Line	:	62 BAYVIEW ST UNIT 23
Second Line	:
City	:	CAMDEN
State	:	ME
Zip	:	04843-2252
Country	:	US
Telephone Number	:	207-706-4163
Fax Number	:	207-706-4173

Provider Business Practice Location Address
First Line	:	62 BAYVIEW ST UNIT 23
Second Line	:
City	:	CAMDEN
State	:	ME
Zip	:	04843-2252
Country	:	US
Telephone Number	:	207-706-4163
Fax Number	:	207-706-4172

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KATHLEEN A DISHNER
Credential	:	APRN
Telephone Number	:	207-504-7631

Provider Enumeration Date	:	05/14/2019
Last Update Date	:	05/14/2019

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Directions to “KATHLEEN DISHNER, INC ” Practice Location

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