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NPI Code Detail

MEDICARE: KRISTINA LYNN IVY MD

MEDICARE: KRISTINA LYNN IVY MD
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
1103TC0700XClinical Psychologist014163NY

General Provider Information

NPI Number : 1538231238
Entity Type Code : Individual
Provider Name (Legal Business Name) : KRISTINA LYNN IVY MD
Provider Business Mailing Address
First Line : 55 POPLAR ST
Second Line : APT. 4K
City : BROOKLYN
State : NY
Zip : 11201-6929
Country : US
Telephone Number : 718-643-2709
Fax Number : 718-346-6747
Provider Business Practice Location Address
First Line : 592 ROCKAWAY AVE
Second Line :
City : BROOKLYN
State : NY
Zip : 11212-5539
Country : US
Telephone Number : 718-345-5000
Fax Number : 718-346-6747
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/15/2006
Last Update Date : 07/08/2007

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