Healthcare Provider Details

I. General information

NPI: 1841713633
Provider Name (Legal Business Name): JENNIFER ALICE KOLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

818 CONGRESS ST
PORTLAND ME
04102-3112
US

V. Phone/Fax

Practice location:
  • Phone: 207-662-0111
  • Fax:
Mailing address:
  • Phone: 207-773-8161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberPA1735
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: