Provider Demographics
NPI:1891460622
Name:IVAKH, ANDI (NP)
Entity type:Individual
Prefix:
First Name:ANDI
Middle Name:
Last Name:IVAKH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANDI
Other - Middle Name:JIN
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3080 DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:WAUKEE
Mailing Address - State:IA
Mailing Address - Zip Code:50263-7621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3930 WESTOWN PKWY STE A
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1035
Practice Address - Country:US
Practice Address - Phone:515-657-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-13
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR203167363LA2100X
VA0024182376363LA2100X
IAH174633363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care