Provider Demographics
NPI:1164865663
Name:LEWIS, IVY (FNP)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 E CANTEBRIA DR
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3542
Mailing Address - Country:US
Mailing Address - Phone:480-650-4390
Mailing Address - Fax:
Practice Address - Street 1:3003 N CENTRAL AVE
Practice Address - Street 2:SUITE 800
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2902
Practice Address - Country:US
Practice Address - Phone:855-821-5128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-15
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP4956363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily