Provider Demographics
NPI:1194927541
Name:EALY, ISHAWN LEVETTE
Entity type:Individual
Prefix:
First Name:ISHAWN
Middle Name:LEVETTE
Last Name:EALY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4549 AGATE DR SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317
Mailing Address - Country:US
Mailing Address - Phone:503-871-4346
Mailing Address - Fax:
Practice Address - Street 1:2421 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1220
Practice Address - Country:US
Practice Address - Phone:503-585-4910
Practice Address - Fax:503-361-2782
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator