Healthcare Provider Details

I. General information

NPI: 1427964113
Provider Name (Legal Business Name): MISS IVANA SOFIA VEGA-RIVERA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10466 TAYLOR RD SW
ETNA OH
43068-3249
US

IV. Provider business mailing address

8147 REYNOLDSWOOD DR
REYNOLDSBURG OH
43068-9328
US

V. Phone/Fax

Practice location:
  • Phone: 614-501-5500
  • Fax:
Mailing address:
  • Phone: 614-578-4655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberCOND20263535-SP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: