Healthcare Provider Details

I. General information

NPI: 1902484587
Provider Name (Legal Business Name): KIMBERLY ANN WELLS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 MARGINAL WAY
PORTLAND ME
04101-2467
US

IV. Provider business mailing address

360 US HIGHWAY 1 BYP UNIT 102
PORTSMOUTH NH
03801-7105
US

V. Phone/Fax

Practice location:
  • Phone: 207-544-9355
  • Fax: 207-544-7756
Mailing address:
  • Phone: 603-410-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number95016926
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95016916
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP241470
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: