Provider Demographics
NPI:1295217958
Name:ISHERWOOD, BAYLEIGH
Entity Type:Individual
Prefix:
First Name:BAYLEIGH
Middle Name:
Last Name:ISHERWOOD
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 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:
Practice Address - Street 1:100 FODEN RD STE 205
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2327
Practice Address - Country:US
Practice Address - Phone:207-874-1489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN68856390200000X
MECNP181111363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program