Healthcare Provider Details

I. General information

NPI: 1003640319
Provider Name (Legal Business Name): IVORY WELLNESS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 LATHROP AVE STE 95
RIVER FOREST IL
60305-1869
US

IV. Provider business mailing address

400 LATHROP AVE STE 95
RIVER FOREST IL
60305-1869
US

V. Phone/Fax

Practice location:
  • Phone: 708-724-9255
  • Fax:
Mailing address:
  • Phone: 708-724-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: VANESSA PRZYBYLA
Title or Position: OWNDER
Credential: FNP-BC
Phone: 708-790-1952