Healthcare Provider Details

I. General information

NPI: 1003548959
Provider Name (Legal Business Name): KORRINNE IVEY WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2022
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 BROAD ST
PROVIDENCE RI
02903-4026
US

IV. Provider business mailing address

345 WHITNEY AVE
NEW HAVEN CT
06511-2348
US

V. Phone/Fax

Practice location:
  • Phone: 513-653-0904
  • Fax:
Mailing address:
  • Phone: 203-503-0450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number193905
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPRN04636
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number10808
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: