Provider Demographics
NPI:1366439929
Name:STOTHOFF, SALLY S (FNP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:S
Last Name:STOTHOFF
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 1:180 KENNEDY MEMORIAL DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4540
Mailing Address - Country:US
Mailing Address - Phone:207-872-5529
Mailing Address - Fax:207-872-9219
Practice Address - Street 1:180 KENNEDY MEMORIAL DR
Practice Address - Street 2:SUITE 204
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4540
Practice Address - Country:US
Practice Address - Phone:207-872-5529
Practice Address - Fax:207-872-9219
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER024050363LF0000X
MECNP81238363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME284350099Medicaid
MEP00066199OtherRAILROAD MEDICARE
ME040915OtherANTHEM
MEAA21889OtherHARVARD PILGRIM HEALTHCA
MEAA21889OtherHARVARD PILGRIM HEALTHCA
MEP20855Medicare UPIN