1164660619 NPI number — KELLY BROWN FNP

Table of content: KELLY BROWN FNP (NPI 1164660619)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164660619 NPI number — KELLY BROWN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
KELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LAPARADE
Provider Other First Name:
KELLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164660619
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 MEDICAL CENTER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIDDEFORD
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04005-9422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-282-9080
Provider Business Mailing Address Fax Number:
207-467-8969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 SHAPE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNEBUNK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04043
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-467-8988
Provider Business Practice Location Address Fax Number:
207-467-8969
Provider Enumeration Date:
01/21/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  060467-23 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X , with the licence number: CNP91015 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1164660619 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1164660619 . This is a "ANTHEM" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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