Provider Demographics
NPI:1093191736
Name:IVANOVA, VERA (NP)
Entity Type:Individual
Prefix:
First Name:VERA
Middle Name:
Last Name:IVANOVA
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 1:15 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-1011
Mailing Address - Country:US
Mailing Address - Phone:204-315-2478
Mailing Address - Fax:207-351-2216
Practice Address - Street 1:15 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-1011
Practice Address - Country:US
Practice Address - Phone:207-351-2478
Practice Address - Fax:207-351-2216
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME53351363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner