Provider Demographics
NPI:1073112561
Name:TODD, IVY A G (PNPC)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:A G
Last Name:TODD
Suffix:
Gender:F
Credentials:PNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-404-8200
Mailing Address - Fax:
Practice Address - Street 1:6 TELCOM DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3072
Practice Address - Country:US
Practice Address - Phone:207-947-0147
Practice Address - Fax:207-990-3365
Is Sole Proprietor?:No
Enumeration Date:2020-10-26
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP211246363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics