Provider Demographics
NPI:1992273072
Name:IVY, ERNESTINE (NP)
Entity type:Individual
Prefix:
First Name:ERNESTINE
Middle Name:
Last Name:IVY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 BILLY COLEMAN RD
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-7134
Mailing Address - Country:US
Mailing Address - Phone:662-295-0151
Mailing Address - Fax:
Practice Address - Street 1:900 STARK RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-3613
Practice Address - Country:US
Practice Address - Phone:662-323-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902734363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily