Provider Demographics
NPI:1104571462
Name:BLACK, IVY (C-NP)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:C-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4467 WORTHINGS CT
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-1471
Mailing Address - Country:US
Mailing Address - Phone:706-405-1195
Mailing Address - Fax:
Practice Address - Street 1:4250 BROWNSVILLE RD
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-2559
Practice Address - Country:US
Practice Address - Phone:678-567-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN195496363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily