Provider Demographics
NPI:1356034912
Name:LI, IVY CHING YUN (CNM, WHNP-BC)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:CHING YUN
Last Name:LI
Suffix:
Gender:F
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2729 MERRILEE DR APT 437
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4444
Mailing Address - Country:US
Mailing Address - Phone:925-407-6486
Mailing Address - Fax:
Practice Address - Street 1:4660 KENMORE AVE STE 902
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1306
Practice Address - Country:US
Practice Address - Phone:703-370-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024187374363LW0102X
367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health