Provider Demographics
NPI:1144663527
Name:IVY, TIA MARIE
Entity type:Individual
Prefix:MS
First Name:TIA
Middle Name:MARIE
Last Name:IVY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4480 KENT RD
Mailing Address - Street 2:123
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-4346
Mailing Address - Country:US
Mailing Address - Phone:330-564-6788
Mailing Address - Fax:
Practice Address - Street 1:4480 KENT RD
Practice Address - Street 2:123
Practice Address - City:STOW
Practice Address - State:OH
Practice Address - Zip Code:44224-4346
Practice Address - Country:US
Practice Address - Phone:330-564-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant