=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194225292
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRO-ELDER CONSULTING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2018
-----------------------------------------------------
Last Update Date | 02/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7 HIGHWOOD ST
-----------------------------------------------------
City | WATERVILLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04901-5739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-873-0705
-----------------------------------------------------
Fax | 855-738-7685
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 HIGHWOOD ST
-----------------------------------------------------
City | WATERVILLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04901-5739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-873-0705
-----------------------------------------------------
Fax | 855-738-7685
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARTHA ANNE EASTMAN
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 207-944-2523
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | CNP101030
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------