Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | R038450 | ME |
NPI | 1023064326 |
---|---|
Provider Name | Kathleen J Mongillo |
First Address | Bridgton, ME 04009-3919 |
Second Address | Portland, ME 04101-2418 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
S58451 | (02) |