Provider Demographics
NPI:1225738859
Name:IVY, HEATHER ANN (CO 61296221)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANN
Last Name:IVY
Suffix:
Gender:F
Credentials:CO 61296221
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9650 15TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98106-2576
Mailing Address - Country:US
Mailing Address - Phone:206-965-1055
Mailing Address - Fax:206-965-1032
Practice Address - Street 1:9650 15TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98106-2576
Practice Address - Country:US
Practice Address - Phone:206-965-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61296221390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program