Provider Demographics
NPI:1174635817
Name:HOTHERSALL, LORETTA A (FNP)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:A
Last Name:HOTHERSALL
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 1:71 US ROUTE 1 STE J
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7168
Mailing Address - Country:US
Mailing Address - Phone:207-396-6433
Mailing Address - Fax:207-396-6436
Practice Address - Street 1:71 US ROUTE 1 STE J
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7168
Practice Address - Country:US
Practice Address - Phone:207-396-6433
Practice Address - Fax:207-396-6436
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER033570363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME293030099Medicaid
ME500020542Medicare PIN
MENP1793Medicare PIN
S79972Medicare UPIN
MENP179301Medicare PIN
ME293030099Medicaid