MEDICARE: DONIVAN LIPSEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	TS939673	OH

General Provider Information

NPI Number	:	1417774217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONIVAN LIPSEY

Provider Business Mailing Address
First Line	:	1812 JASON DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43227-2555
Country	:	US
Telephone Number	:	614-680-2131
Fax Number	:

Provider Business Practice Location Address
First Line	:	1812 JASON DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43227-2555
Country	:	US
Telephone Number	:	614-680-2131
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/23/2024
Last Update Date	:	09/23/2024

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Directions to “ DONIVAN LIPSEY ” Practice Location

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