Healthcare Provider Details

I. General information

NPI: 1740957612
Provider Name (Legal Business Name): IVY LAPAZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALBUQUERQUE NM 87131
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

1 CENTRAL AVE NW APT 631
ALBUQUERQUE NM
87102-4524
US

V. Phone/Fax

Practice location:
  • Phone: 505-277-0111
  • Fax:
Mailing address:
  • Phone: 575-973-0597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: