Healthcare Provider Details

I. General information

NPI: 1164865663
Provider Name (Legal Business Name): IVY LEWIS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2013
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 N CENTRAL AVE SUITE 800
PHOENIX AZ
85012-2902
US

IV. Provider business mailing address

748 E CANTEBRIA DR
GILBERT AZ
85296-3542
US

V. Phone/Fax

Practice location:
  • Phone: 855-821-5128
  • Fax:
Mailing address:
  • Phone: 480-650-4390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4956
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: