Provider Demographics
NPI:1306583182
Name:INGELLIS, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:INGELLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 AUBURN ST
Mailing Address - Street 2:STE J #1180
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2119
Mailing Address - Country:US
Mailing Address - Phone:203-577-9660
Mailing Address - Fax:
Practice Address - Street 1:15 OAK ST
Practice Address - Street 2:
Practice Address - City:SPRINGVALE
Practice Address - State:ME
Practice Address - Zip Code:04083-1926
Practice Address - Country:US
Practice Address - Phone:207-490-6900
Practice Address - Fax:207-459-2822
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP221094363LP0808X, 363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program