Provider Demographics
NPI:1063195253
Name:IVORY, SHARISSE LIN (APRN)
Entity type:Individual
Prefix:
First Name:SHARISSE
Middle Name:LIN
Last Name:IVORY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:SHARISSE
Other - Middle Name:LIN
Other - Last Name:PARKS, LANIER, DESHONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, CRT
Mailing Address - Street 1:835 OAKLEY SEAVER DR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1968
Mailing Address - Country:US
Mailing Address - Phone:352-241-9282
Mailing Address - Fax:352-241-4282
Practice Address - Street 1:835 OAKLEY SEAVER DR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1968
Practice Address - Country:US
Practice Address - Phone:352-241-9282
Practice Address - Fax:352-241-4282
Is Sole Proprietor?:No
Enumeration Date:2023-08-14
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11028060363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health