Healthcare Provider Details

I. General information

NPI: 1518592278
Provider Name (Legal Business Name): IVY RYNEARSON CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 UNITY PL STE 355
LAFAYETTE IN
47905-5761
US

IV. Provider business mailing address

PO BOX 4699
LAFAYETTE IN
47903-4699
US

V. Phone/Fax

Practice location:
  • Phone: 765-807-7988
  • Fax: 765-807-7989
Mailing address:
  • Phone: 765-446-5417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number71009854A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: