Healthcare Provider Details

I. General information

NPI: 1295916286
Provider Name (Legal Business Name): MARVIS M. IVEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2007
Last Update Date: 11/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

843 ARBOR CT
STONE MOUNTAIN GA
30088-2371
US

IV. Provider business mailing address

843 ARBOR CT
STONE MOUNTAIN GA
30088-2371
US

V. Phone/Fax

Practice location:
  • Phone: 404-296-4026
  • Fax:
Mailing address:
  • Phone: 404-296-4026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberRN054334
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberRN054334
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN054334
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number5435721
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: