Provider Demographics
NPI:1538231238
Name:IVY, KRISTINA LYNN (MD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:LYNN
Last Name:IVY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 POPLAR ST
Mailing Address - Street 2:APT. 4K
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-6929
Mailing Address - Country:US
Mailing Address - Phone:718-643-2709
Mailing Address - Fax:718-346-6747
Practice Address - Street 1:592 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-5539
Practice Address - Country:US
Practice Address - Phone:718-345-5000
Practice Address - Fax:718-346-6747
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014163103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical