Provider Demographics
NPI:1629207410
Name:EBERSOLE, JOYCE AILEEN
Entity Type:Individual
Prefix:
First Name:JOYCE
Middle Name:AILEEN
Last Name:EBERSOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 HOPKINS POND RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:ME
Mailing Address - Zip Code:04428-6195
Mailing Address - Country:US
Mailing Address - Phone:207-843-5626
Mailing Address - Fax:
Practice Address - Street 1:285 HOPKINS POND RD
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:ME
Practice Address - Zip Code:04428-6195
Practice Address - Country:US
Practice Address - Phone:207-843-5626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERO27935163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432341900Medicaid