Provider Demographics
NPI:1063955011
Name:EMERDELLO, KATHLEEN DOLAN EMERSON (CNM, WHNP, RN)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DOLAN EMERSON
Last Name:EMERDELLO
Suffix:
Gender:F
Credentials:CNM, WHNP, RN
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:DOLAN
Other - Last Name:EMERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM, WHNP, RN
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:510-300-8039
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95048259163W00000X
MERN80303163W00000X
CA95005404363LW0102X
CA235826367A00000X
MECNM212013367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MECNM03965OtherCNM03965