Provider Demographics
NPI:1962481283
Name:FARNSWORTH, ELLEN JANE (NP)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:JANE
Last Name:FARNSWORTH
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 1:55 OLD MAST RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1935
Mailing Address - Country:US
Mailing Address - Phone:207-671-4180
Mailing Address - Fax:
Practice Address - Street 1:55 OLD MAST RD
Practice Address - Street 2:NURSE PRACTITIONER CARE LLC
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1935
Practice Address - Country:US
Practice Address - Phone:207-671-4180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-13
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEAP081049363LA2200X, 363LA2200X
MECNP81049363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431776399Medicaid
S80813Medicare UPIN
FANP4964Medicare ID - Type Unspecified