=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558935338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMUEL G KINGSLEY NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2021
-----------------------------------------------------
Last Update Date | 10/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 PLEASANT HILL RD STE 204
-----------------------------------------------------
City | SCARBOROUGH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04074-7678
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-387-4801
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 233 JOB RD
-----------------------------------------------------
City | STANDISH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04084-6530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 78-321-2122
-----------------------------------------------------
Fax | 207-799-9887
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | CNP211320
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------