Provider Demographics
NPI:1083673966
Name:HOUSE, THORA (FNP)
Entity Type:Individual
Prefix:
First Name:THORA
Middle Name:
Last Name:HOUSE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 99
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:ME
Mailing Address - Zip Code:04457-0099
Mailing Address - Country:US
Mailing Address - Phone:207-794-6700
Mailing Address - Fax:207-794-6777
Practice Address - Street 1:175 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:ME
Practice Address - Zip Code:04457-0000
Practice Address - Country:US
Practice Address - Phone:207-794-6700
Practice Address - Fax:207-794-6466
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME025743363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME201837OtherNGS
ME257420099Medicaid
ME035045OtherANTHEM
MENP0984Medicare ID - Type UnspecifiedNHIC
ME257420099Medicaid