MEDICARE: IVY MORGAN WALLERICH

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	372600000X	Adult Companion

General Provider Information

NPI Number	:	1285428110
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVY MORGAN WALLERICH

Provider Business Mailing Address
First Line	:	1515 W 13TH ST
Second Line	:
City	:	NORTH PLATTE
State	:	NE
Zip	:	69101-7202
Country	:	US
Telephone Number	:	308-641-7891
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 W 13TH ST
Second Line	:
City	:	NORTH PLATTE
State	:	NE
Zip	:	69101-7202
Country	:	US
Telephone Number	:	402-853-4995
Fax Number	:

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

Provider Enumeration Date	:	04/07/2025
Last Update Date	:	04/07/2025

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