MEDICARE: IVY LI-GARZONA

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	363LF0000X	Family Nurse Practitioner	20757	CA

General Provider Information

NPI Number	:	1417242280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVY LI-GARZONA

Provider Business Mailing Address
First Line	:	5841 JAMESON CT
Second Line	:
City	:	CARMICHAEL
State	:	CA
Zip	:	95608-0895
Country	:	US
Telephone Number	:	916-485-9800
Fax Number	:

Provider Business Practice Location Address
First Line	:	5841 JAMESON CT
Second Line	:
City	:	CARMICHAEL
State	:	CA
Zip	:	95608-0895
Country	:	US
Telephone Number	:	916-485-9800
Fax Number	:

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

Provider Enumeration Date	:	06/09/2011
Last Update Date	:	10/24/2022

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