Healthcare Provider Details

I. General information

NPI: 1639573421
Provider Name (Legal Business Name): KIMBERLY ANN MARSHALL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIMBERLY A BRADHAM NP

II. Dates (important events)

Enumeration Date: 10/22/2014
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 MAIN ST STE D
ELLSWORTH ME
04605-1919
US

IV. Provider business mailing address

102 MAIN ST STE D
ELLSWORTH ME
04605-1919
US

V. Phone/Fax

Practice location:
  • Phone: 207-613-7500
  • Fax:
Mailing address:
  • Phone: 207-613-7500
  • Fax: 207-613-7600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0024172127
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCNP211108
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0024172127
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP211108
License Number StateME
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number0024172127
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: