Provider Demographics
NPI:1053368993
Name:PENNELL, NICHOLAS D (FNP)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:D
Last Name:PENNELL
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 WASHINGTON AVE
Mailing Address - Street 2:301
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3636
Mailing Address - Country:US
Mailing Address - Phone:207-780-6565
Mailing Address - Fax:207-878-6565
Practice Address - Street 1:1321 WASHINGTON AVE
Practice Address - Street 2:301
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3636
Practice Address - Country:US
Practice Address - Phone:207-780-6565
Practice Address - Fax:207-878-6565
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER049269363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30347108Medicaid
ME433046299Medicaid
MENP530101Medicare PIN
MENP5301Medicare PIN
NH30347108Medicaid