Provider Demographics
NPI:1083126379
Name:PLYMOUTH, IVANNA (NP)
Entity Type:Individual
Prefix:MISS
First Name:IVANNA
Middle Name:
Last Name:PLYMOUTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2090 ARBROTH CT
Mailing Address - Street 2:
Mailing Address - City:WALDORF
Mailing Address - State:MD
Mailing Address - Zip Code:20601-3787
Mailing Address - Country:US
Mailing Address - Phone:252-268-2608
Mailing Address - Fax:
Practice Address - Street 1:7503 SURRATTS RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3358
Practice Address - Country:US
Practice Address - Phone:301-877-4656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010033363LA2100X, 363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care