Provider Demographics
NPI:1629233440
Name:SPONSELLER, AMELIA KRISTINE (FNP)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:KRISTINE
Last Name:SPONSELLER
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:PO BOX 9746
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5040
Mailing Address - Country:US
Mailing Address - Phone:207-791-3888
Mailing Address - Fax:207-828-7850
Practice Address - Street 1:153 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9052
Practice Address - Country:US
Practice Address - Phone:207-799-8596
Practice Address - Fax:207-799-1730
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP18920363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MES400217305Medicare PIN