Healthcare Provider Details

I. General information

NPI: 1578848735
Provider Name (Legal Business Name): LAURA ANN IVEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 MEDICAL CAMPUS DR NW STE 207
SUPPLY NC
28462-4094
US

IV. Provider business mailing address

PO BOX 96191
CHARLOTTE NC
28296-6191
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-3642
  • Fax: 770-962-3643
Mailing address:
  • Phone: 770-962-3642
  • Fax: 770-962-3643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-03172
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-03172
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: