Healthcare Provider Details

I. General information

NPI: 1568547818
Provider Name (Legal Business Name): NENA R. IVEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4604 NE STALLINGS DR
NACOGDOCHES TX
75965-1608
US

IV. Provider business mailing address

4800 NE STALLINGS DR STE 109
NACOGDOCHES TX
75965-1250
US

V. Phone/Fax

Practice location:
  • Phone: 936-559-8770
  • Fax: 936-559-8773
Mailing address:
  • Phone: 936-559-8770
  • Fax: 936-559-8773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberPA05023
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: