Healthcare Provider Details

I. General information

NPI: 1205119005
Provider Name (Legal Business Name): IVEY E. ALLEN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MIMOSA DR
THOMASVILLE GA
31792-6676
US

IV. Provider business mailing address

900 CAIRO RD
THOMASVILLE GA
31792-4255
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-8881
  • Fax: 229-227-5187
Mailing address:
  • Phone: 229-227-5102
  • Fax: 229-227-5187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number006083
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: