Healthcare Provider Details

I. General information

NPI: 1508168642
Provider Name (Legal Business Name): IVY S LEIGHT M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2010
Last Update Date: 05/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 VIVIGEN WAY
SANTA FE NM
87505-5600
US

IV. Provider business mailing address

2000 VIVIGEN WAY
SANTA FE NM
87505-5600
US

V. Phone/Fax

Practice location:
  • Phone: 800-848-4436
  • Fax: 505-438-2269
Mailing address:
  • Phone: 800-848-4436
  • Fax: 505-438-2269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: