Provider Demographics
NPI:1093420200
Name:IVERY, EQUIELLA
Entity Type:Individual
Prefix:
First Name:EQUIELLA
Middle Name:
Last Name:IVERY
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 1:4295 BALL PARK RD
Mailing Address - Street 2:
Mailing Address - City:FORDOCHE
Mailing Address - State:LA
Mailing Address - Zip Code:70732-3112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4295 BALL PARK RD
Practice Address - Street 2:
Practice Address - City:FORDOCHE
Practice Address - State:LA
Practice Address - Zip Code:70732-3112
Practice Address - Country:US
Practice Address - Phone:225-274-4155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver