Provider Demographics
NPI:1972310035
Name:LEWIS, IVY LEWIS (LPN)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:LEWIS
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2293 JACQUELINE LN
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-1867
Mailing Address - Country:US
Mailing Address - Phone:208-317-3364
Mailing Address - Fax:
Practice Address - Street 1:4414 DEER AVE
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2668
Practice Address - Country:US
Practice Address - Phone:208-317-3364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-12
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID14873164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse