Provider Demographics
NPI:1700594066
Name:LEGACY, JODIE MAXINE (APRN)
Entity Type:Individual
Prefix:MISS
First Name:JODIE
Middle Name:MAXINE
Last Name:LEGACY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 FITZGERALD RD
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:VT
Mailing Address - Zip Code:05661-8911
Mailing Address - Country:US
Mailing Address - Phone:802-272-2649
Mailing Address - Fax:
Practice Address - Street 1:130 FISHER RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:VT
Practice Address - Zip Code:05602-9516
Practice Address - Country:US
Practice Address - Phone:802-225-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT026.0034921163W00000X
VT101.0135915PROV363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse