Provider Demographics
NPI:1083209266
Name:IANTSEVYCH, NATALIIA
Entity Type:Individual
Prefix:
First Name:NATALIIA
Middle Name:
Last Name:IANTSEVYCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 FOREST AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1884
Mailing Address - Country:US
Mailing Address - Phone:207-979-5753
Mailing Address - Fax:
Practice Address - Street 1:1250 FOREST AVE STE 301
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1884
Practice Address - Country:US
Practice Address - Phone:207-979-5753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME211076363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME363LF0000XMedicaid
ME211076OtherLICENSE