Provider Demographics
NPI:1558695783
Name:ERNST, KELLY E W (FNP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:E W
Last Name:ERNST
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:WELCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:100 BRICKHILL AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1999
Practice Address - Country:US
Practice Address - Phone:207-773-1728
Practice Address - Fax:207-772-4062
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP111042363LF0000X
MERN62266163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1558695783Medicaid