Provider Demographics
NPI:1386308955
Name:IVY, MARSHE (NP)
Entity type:Individual
Prefix:
First Name:MARSHE
Middle Name:
Last Name:IVY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8984 SIERRA ST
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1952
Mailing Address - Country:US
Mailing Address - Phone:510-229-8321
Mailing Address - Fax:
Practice Address - Street 1:582 E HARDING WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-6110
Practice Address - Country:US
Practice Address - Phone:209-442-6077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily