Healthcare Provider Details

I. General information

NPI: 1457291619
Provider Name (Legal Business Name): KONALIFE, LLC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 MAIN ST UNIT 2S
MOUNT DESERT ME
04660-6318
US

IV. Provider business mailing address

PO BOX 687
MOUNT DESERT ME
04660-0687
US

V. Phone/Fax

Practice location:
  • Phone: 207-244-4111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATI DEREVERE
Title or Position: OWNER
Credential:
Phone: 207-479-2583