Provider Demographics
NPI:1063199750
Name:IVY, KHANDRA ARIES
Entity type:Individual
Prefix:
First Name:KHANDRA
Middle Name:ARIES
Last Name:IVY
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:KHANDRA
Other - Middle Name:ARIES
Other - Last Name:IVY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CMAA/PHLEBOTOMIST
Mailing Address - Street 1:127 DRIVE 156
Mailing Address - Street 2:
Mailing Address - City:OKOLONA
Mailing Address - State:MS
Mailing Address - Zip Code:38860-9677
Mailing Address - Country:US
Mailing Address - Phone:662-760-3031
Mailing Address - Fax:
Practice Address - Street 1:127 DRIVE 156
Practice Address - Street 2:
Practice Address - City:OKOLONA
Practice Address - State:MS
Practice Address - Zip Code:38860-9677
Practice Address - Country:US
Practice Address - Phone:662-760-3031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy