Provider Demographics
NPI:1699258319
Name:IVERS, MARLISSA HINKLE (CPM, LM)
Entity type:Individual
Prefix:
First Name:MARLISSA
Middle Name:HINKLE
Last Name:IVERS
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5721 LAKE MURRAY BLVD APT 18
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-1908
Mailing Address - Country:US
Mailing Address - Phone:919-389-0354
Mailing Address - Fax:
Practice Address - Street 1:2835 CAMINO DEL RIO S STE 210
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3825
Practice Address - Country:US
Practice Address - Phone:919-389-0354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-09
Last Update Date:2018-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA538176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife