Provider Demographics
NPI:1851850812
Name:LY, ANN (MD)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 MAGNOLIA AVE
Mailing Address - Street 2:GME OFFICE
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-4199
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:GME OFFICE
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4199
Practice Address - Country:US
Practice Address - Phone:951-788-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF2022934OtherCALIFORNIA DRIVER'S LICENSE