Provider Demographics
NPI:1528502002
Name:KRISTEN MICKKELSEN PMHNP BC LLC
Entity type:Organization
Organization Name:KRISTEN MICKKELSEN PMHNP BC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MIKKELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:207-536-3088
Mailing Address - Street 1:106 SUNSET RD
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-2490
Mailing Address - Country:US
Mailing Address - Phone:207-536-3088
Mailing Address - Fax:207-536-3092
Practice Address - Street 1:1321 WASHINGTON AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3636
Practice Address - Country:US
Practice Address - Phone:207-536-3088
Practice Address - Fax:207-536-3092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP121069363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty