MEDICARE: CANDICE ELLIS APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP2300X	Primary Care Nurse Practitioner	RN2310377	MA
2	363LP2300X	Primary Care Nurse Practitioner	CNP231278	ME
3	163W00000X	Registered Nurse	074678-21	NH
4	163W00000X	Registered Nurse	2310377	MA
5	363L00000X	Nurse Practitioner	074678-23	NH

General Provider Information

NPI Number	:	1922531011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CANDICE ELLIS APRN

Provider Business Mailing Address
First Line	:	22 BRAMHALL ST
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04102-3175
Country	:	US
Telephone Number	:	207-662-3500
Fax Number	:

Provider Business Practice Location Address
First Line	:	225 GORHAM RD STE 200
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-2462
Country	:	US
Telephone Number	:	800-757-3326
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2017
Last Update Date	:	05/05/2025

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Directions to “ CANDICE ELLIS APRN” Practice Location

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