Healthcare Provider Details

I. General information

NPI: 1265230668
Provider Name (Legal Business Name): IVY JO EVA GULLICKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IVY JOEVA

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 CORONADO ST APT D
VENTURA CA
93001-5532
US

IV. Provider business mailing address

29 CORONADO ST APT D
VENTURA CA
93001-5532
US

V. Phone/Fax

Practice location:
  • Phone: 310-634-8192
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: