Healthcare Provider Details

I. General information

NPI: 1578479333
Provider Name (Legal Business Name): MIKAELA IVY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 COUNTY ROAD 210 W
SAINT JOHNS FL
32259-2016
US

IV. Provider business mailing address

260 GRAND CYPRESS DR APT 440
SAINT JOHNS FL
32259-1983
US

V. Phone/Fax

Practice location:
  • Phone: 904-230-3933
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS71380
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: