Healthcare Provider Details

I. General information

NPI: 1093784183
Provider Name (Legal Business Name): WILLIE D IVEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W 5TH AVE SUITE 500
SPOKANE WA
99204-2756
US

IV. Provider business mailing address

601 W 5TH AVE STE 400
SPOKANE WA
99204-2715
US

V. Phone/Fax

Practice location:
  • Phone: 509-344-2663
  • Fax: 509-624-9179
Mailing address:
  • Phone: 509-344-2663
  • Fax: 509-624-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN00144573
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: