Provider Demographics
NPI:1578958161
Name:ANNIS, JODY
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:
Last Name:ANNIS
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 1:891 W MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DOVER FOXCROFT
Mailing Address - State:ME
Mailing Address - Zip Code:04426-1059
Mailing Address - Country:US
Mailing Address - Phone:207-564-4157
Mailing Address - Fax:
Practice Address - Street 1:891 W MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426-1059
Practice Address - Country:US
Practice Address - Phone:207-564-4157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN35539163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator