Provider Demographics
NPI:1730843624
Name:IVY, DEBORA (RN, BSN, PHN, CBIS)
Entity type:Individual
Prefix:
First Name:DEBORA
Middle Name:
Last Name:IVY
Suffix:
Gender:F
Credentials:RN, BSN, PHN, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 MAMMOTH AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3649
Mailing Address - Country:US
Mailing Address - Phone:714-887-4997
Mailing Address - Fax:
Practice Address - Street 1:2070 CENTURY PARK E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-1907
Practice Address - Country:US
Practice Address - Phone:714-887-4997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA562534163WC1500X
CA95260258163WR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0400XNursing Service ProvidersRegistered NurseRehabilitation
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health