Provider Demographics
NPI:1487413977
Name:IVORY, VICKIE
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:IVORY
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 1:137 N BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30607-1901
Mailing Address - Country:US
Mailing Address - Phone:706-443-3431
Mailing Address - Fax:
Practice Address - Street 1:137 N BLUFF RD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30607-1901
Practice Address - Country:US
Practice Address - Phone:706-443-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-18
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN067284164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse