Healthcare Provider Details

I. General information

NPI: 1962481283
Provider Name (Legal Business Name): ELLEN JANE FARNSWORTH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 10/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 OLD MAST RD NURSE PRACTITIONER CARE LLC
PORTLAND ME
04102-1935
US

IV. Provider business mailing address

55 OLD MAST RD
PORTLAND ME
04102-1935
US

V. Phone/Fax

Practice location:
  • Phone: 207-671-4180
  • Fax:
Mailing address:
  • Phone: 207-671-4180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP081049
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCNP81049
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: