MEDICARE: JENNIFER MARIE IVES LPN

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	164W00000X	Licensed Practical Nurse	LP035815	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LP035815	OTHER	AZ	LPN

General Provider Information

NPI Number	:	1326214107
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MARIE IVES LPN

Provider Business Mailing Address
First Line	:	711 E MISSOURI AVE STE 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2824
Country	:	US
Telephone Number	:	602-604-0548
Fax Number	:

Provider Business Practice Location Address
First Line	:	711 E MISSOURI AVE STE 110
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85014-2824
Country	:	US
Telephone Number	:	602-604-0548
Fax Number	:

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

Provider Enumeration Date	:	05/01/2008
Last Update Date	:	05/01/2008

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