Provider Demographics
NPI:1689618563
Name:ELLENSOHN, KRISTEN M (APRN FNP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:M
Last Name:ELLENSOHN
Suffix:
Gender:F
Credentials:APRN FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 STATE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3776
Mailing Address - Country:US
Mailing Address - Phone:207-400-8500
Mailing Address - Fax:207-400-8508
Practice Address - Street 1:144 STATE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3776
Practice Address - Country:US
Practice Address - Phone:207-400-8500
Practice Address - Fax:207-400-8508
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209004972363LF0000X
MECNP141022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECNP141022Medicaid
IL209004972Medicaid