Provider Demographics
NPI:1689636607
Name:BULTHUIS, LISA L (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:BULTHUIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 GANNETT DRIVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:100 FODEN RD, WEST
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-523-3904
Practice Address - Fax:207-523-8588
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP81553363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400409706OtherMEDICARE
MEE400409710OtherMEDICARE
MENP271202Medicare PIN
MEE400409710OtherMEDICARE
MEE400229846Medicare PIN
MENP271201Medicare PIN
MENP2712Medicare PIN
MEP15445Medicare UPIN