Provider Demographics
NPI:1225253362
Name:CONGLETON, SALLY KAY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:KAY
Last Name:CONGLETON
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 1:39 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04268-5501
Mailing Address - Country:US
Mailing Address - Phone:207-743-9645
Mailing Address - Fax:207-743-6192
Practice Address - Street 1:39 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5501
Practice Address - Country:US
Practice Address - Phone:207-743-9645
Practice Address - Fax:207-743-6192
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081449363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CONP3539Medicare ID - Type Unspecified
P42452Medicare UPIN