Provider Demographics
NPI:1558935338
Name:KINGSLEY, SAMUEL G (NP)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:G
Last Name:KINGSLEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 JOB RD
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-6530
Mailing Address - Country:US
Mailing Address - Phone:078-321-2122
Mailing Address - Fax:207-799-9887
Practice Address - Street 1:15 PLEASANT HILL RD STE 204
Practice Address - Street 2:
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-7678
Practice Address - Country:US
Practice Address - Phone:207-387-4801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP211320363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health