Healthcare Provider Details

I. General information

NPI: 1104786151
Provider Name (Legal Business Name): LIGHTHOUSE DIABETES CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 MALLARD DR
YORK ME
03909-1361
US

IV. Provider business mailing address

26 MALLARD DR
YORK ME
03909-1361
US

V. Phone/Fax

Practice location:
  • Phone: 207-814-8718
  • Fax:
Mailing address:
  • Phone: 207-814-8718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: EMILY APPLETON
Title or Position: PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 631-664-2112