Provider Demographics
NPI:1508840091
Name:NEVELLS, KIMBERLY A (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:NEVELLS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 US HIGHWAY 1 BYP UNIT 102
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7105
Mailing Address - Country:US
Mailing Address - Phone:603-410-6700
Mailing Address - Fax:603-319-8308
Practice Address - Street 1:1420 MAIN ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-3680
Practice Address - Country:US
Practice Address - Phone:207-850-5744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0390656363L00000X
MECNP81440363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1508840091Medicaid
ME003016501Medicare PIN
MEMM4487Medicare PIN