Provider Demographics
NPI:1417774217
Name:LIPSEY, DONIVAN
Entity type:Individual
Prefix:
First Name:DONIVAN
Middle Name:
Last Name:LIPSEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1812 JASON DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43227-2555
Mailing Address - Country:US
Mailing Address - Phone:614-680-2131
Mailing Address - Fax:
Practice Address - Street 1:1812 JASON DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43227-2555
Practice Address - Country:US
Practice Address - Phone:614-680-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHTS939673172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker