Provider Demographics
NPI:1285428110
Name:WALLERICH, IVY MORGAN
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:MORGAN
Last Name:WALLERICH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH PLATTE
Mailing Address - State:NE
Mailing Address - Zip Code:69101-7202
Mailing Address - Country:US
Mailing Address - Phone:308-641-7891
Mailing Address - Fax:
Practice Address - Street 1:1515 W 13TH ST
Practice Address - Street 2:
Practice Address - City:NORTH PLATTE
Practice Address - State:NE
Practice Address - Zip Code:69101-7202
Practice Address - Country:US
Practice Address - Phone:402-853-4995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion