Provider Demographics
NPI:1033714860
Name:LAGE, IVONNE
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:
Last Name:LAGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 W 16TH AVE STE 9
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7101
Mailing Address - Country:US
Mailing Address - Phone:786-353-0085
Mailing Address - Fax:305-490-6394
Practice Address - Street 1:4410 W 16TH AVE STE 9
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7101
Practice Address - Country:US
Practice Address - Phone:786-353-0085
Practice Address - Fax:305-490-6394
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS45639183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist