Healthcare Provider Details

I. General information

NPI: 1053368993
Provider Name (Legal Business Name): NICHOLAS D PENNELL FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 WASHINGTON AVE 301
PORTLAND ME
04103-3636
US

IV. Provider business mailing address

1321 WASHINGTON AVE 301
PORTLAND ME
04103-3636
US

V. Phone/Fax

Practice location:
  • Phone: 207-780-6565
  • Fax: 207-878-6565
Mailing address:
  • Phone: 207-780-6565
  • Fax: 207-878-6565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR049269
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: