MEDICARE: IVY DZIFA DZIVENU

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	0024192399	VA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	NP500125648	DC

General Provider Information

NPI Number	:	1215741301
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVY DZIFA DZIVENU

Provider Business Mailing Address
First Line	:	3301 RICHMOND HWY # 1360
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22305-3044
Country	:	US
Telephone Number	:	571-275-5935
Fax Number	:

Provider Business Practice Location Address
First Line	:	3301 RICHMOND HWY # 1360
Second Line	:
City	:	ALEXANDRIA
State	:	VA
Zip	:	22305-3044
Country	:	US
Telephone Number	:	571-275-5935
Fax Number	:

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

Provider Enumeration Date	:	02/06/2025
Last Update Date	:	02/17/2026

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