MEDICARE: KATRINA IVORY PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	4704377051	MI
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0041323	OH

General Provider Information

NPI Number	:	1063362853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATRINA IVORY PMHNP-BC

Provider Business Mailing Address
First Line	:	11000 W MCNICHOLS RD STE 3231029
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-2357
Country	:	US
Telephone Number	:	313-649-5188
Fax Number	:

Provider Business Practice Location Address
First Line	:	11000 W MCNICHOLS RD STE 3231029
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-2357
Country	:	US
Telephone Number	:	313-649-5188
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2026
Last Update Date	:	03/11/2026

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