Provider Demographics
NPI:1215741301
Name:DZIVENU, IVY DZIFA
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:DZIFA
Last Name:DZIVENU
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 1:6308 FIVE MILE CENTRE PARK
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-5508
Mailing Address - Country:US
Mailing Address - Phone:540-642-0883
Mailing Address - Fax:
Practice Address - Street 1:6308 FIVE MILE CENTRE PARK
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-5508
Practice Address - Country:US
Practice Address - Phone:540-642-0883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-06
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024192399363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health