Healthcare Provider Details

I. General information

NPI: 1114689817
Provider Name (Legal Business Name): NICOLE SHAWNTAY KELLY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2021
Last Update Date: 10/10/2021
Certification Date: 09/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAIN ST
LEWISTON ME
04240-7041
US

IV. Provider business mailing address

18 LAURIER ST
LEWISTON ME
04240-4106
US

V. Phone/Fax

Practice location:
  • Phone: 207-795-0111
  • Fax:
Mailing address:
  • Phone: 207-332-0522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP211493
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: