Provider Demographics
NPI:1023064326
Name:MONGILLO, KATHLEEN J (MS,ARNP,BC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:J
Last Name:MONGILLO
Suffix:
Gender:F
Credentials:MS,ARNP,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 S HIGH ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04009-3919
Mailing Address - Country:US
Mailing Address - Phone:603-447-6339
Mailing Address - Fax:
Practice Address - Street 1:200 LANCASTER STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2418
Practice Address - Country:US
Practice Address - Phone:207-772-2133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER038450363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MENS8017Medicare ID - Type UnspecifiedMEDICARE
S58451Medicare UPIN