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General NPI Number Information
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NPI Number | 1073837670
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Entity Type | Individual
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Provider Name | MS. LISA IVY
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Gender | Female
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Dates
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Enumeration Date | 03/25/2010
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Last Update Date | 03/25/2010
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Provider Practice Location Address
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Address Line | 450 EL DORADO BLVD # 720
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City | WEBSTER
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State | TX
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Zip | 77598-2317
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Country | US
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Telephone | 281-282-7027
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Fax | 281-862-9148
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Provider Business Mailing Address
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Address Line | PO BOX 2049
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City | CHANNELVIEW
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State | TX
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Zip | 77530-8049
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Country | US
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Telephone | 281-282-7027
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Fax | 281-862-9148
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number |
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License Number State |
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