Healthcare Provider Details

I. General information

NPI: 1073173597
Provider Name (Legal Business Name): JULIANNE ALICE IVY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 NEW BRITAIN AVE
HARTFORD CT
06106-3305
US

IV. Provider business mailing address

19 GRAND ST
MIDDLETOWN CT
06457-2705
US

V. Phone/Fax

Practice location:
  • Phone: 860-545-9300
  • Fax: 860-343-7379
Mailing address:
  • Phone: 860-347-6971
  • Fax: 860-343-7379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number85390
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2019018901
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: