Healthcare Provider Details

I. General information

NPI: 1578958161
Provider Name (Legal Business Name): JODY ANNIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

891 W MAIN ST SUITE 200
DOVER FOXCROFT ME
04426-1059
US

IV. Provider business mailing address

891 W MAIN ST SUITE 200
DOVER FOXCROFT ME
04426-1059
US

V. Phone/Fax

Practice location:
  • Phone: 207-564-4157
  • Fax:
Mailing address:
  • Phone: 207-564-4157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN35539
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: