Provider Demographics
NPI:1063480366
Name:IVY, LAURA ANN (LDN RD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:IVY
Suffix:
Gender:F
Credentials:LDN RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 PINES RD
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71119-7315
Mailing Address - Country:US
Mailing Address - Phone:318-631-4109
Mailing Address - Fax:
Practice Address - Street 1:510 E STONER AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4243
Practice Address - Country:US
Practice Address - Phone:318-221-8411
Practice Address - Fax:318-429-5724
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA884597133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered