Healthcare Provider Details

I. General information

NPI: 1023409034
Provider Name (Legal Business Name): IVY MCKENZIE CARSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2015
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8550 SANTA MONICA BLVD FL 2
WEST HOLLYWOOD CA
90069-4496
US

IV. Provider business mailing address

8550 SANTA MONICA BLVD FL 2
WEST HOLLYWOOD CA
90069-4496
US

V. Phone/Fax

Practice location:
  • Phone: 909-962-1260
  • Fax: 323-307-7140
Mailing address:
  • Phone: 909-962-1260
  • Fax: 323-307-7140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704279990
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704279990
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704279990
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: