MEDICARE: MARVIS M. IVEY RN

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	163W00000X	Registered Nurse	RN054334	GA
2	163WG0000X	General Practice Registered Nurse	5435721	NY
3	310400000X	Assisted Living Facility	RN054334	GA
4	311ZA0620X	Adult Care Home Facility	RN054334	GA

General Provider Information

NPI Number	:	1295916286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARVIS M. IVEY RN

Provider Business Mailing Address
First Line	:	843 ARBOR CT
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2371
Country	:	US
Telephone Number	:	404-296-4026
Fax Number	:

Provider Business Practice Location Address
First Line	:	843 ARBOR CT
Second Line	:
City	:	STONE MOUNTAIN
State	:	GA
Zip	:	30088-2371
Country	:	US
Telephone Number	:	404-296-4026
Fax Number	:

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

Provider Enumeration Date	:	11/18/2007
Last Update Date	:	11/18/2007

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