Provider Demographics
NPI:1083811194
Name:SHEEHAN, IVY LEE (RD, CDE)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:LEE
Last Name:SHEEHAN
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:IVY
Other - Middle Name:
Other - Last Name:BUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 863407
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3407
Mailing Address - Country:US
Mailing Address - Phone:941-917-3270
Mailing Address - Fax:941-917-3275
Practice Address - Street 1:1921 WALDEMERE ST STE 512
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2941
Practice Address - Country:US
Practice Address - Phone:941-917-3270
Practice Address - Fax:941-917-3275
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0425133V00000X
FLND9738133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0974309Medicare PIN
KYK007540Medicare PIN
KYK095260Medicare PIN