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General NPI Number Information
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NPI Number | 1942201868
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Entity Type | Individual
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Provider Name | IVY FASKE M.D.
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Gender | Female
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Dates
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Enumeration Date | 08/02/2005
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Last Update Date | 12/01/2020
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Provider Practice Location Address
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Address Line | 3365 BURNS RD SUITE 206
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City | PALM BEACH GARDENS
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State | FL
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Zip | 33410-4303
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Country | US
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Telephone | 561-626-4677
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Fax | 561-626-6995
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Provider Business Mailing Address
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Address Line | 11211 PROSPERITY FARMS RD STE A102
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City | PALM BEACH GARDENS
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State | FL
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Zip | 33410-3479
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Country | US
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Telephone | 561-626-4677
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Fax | 561-293-7060
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME 49705
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License Number State | FL
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