Provider Demographics
NPI:1346791522
Name:IVEY, LEROY GEORGE
Entity Type:Individual
Prefix:MR
First Name:LEROY
Middle Name:GEORGE
Last Name:IVEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 SAN MARINO BLVD
Mailing Address - Street 2:APT 308
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-8622
Mailing Address - Country:US
Mailing Address - Phone:954-801-5042
Mailing Address - Fax:
Practice Address - Street 1:4021 SAN MARINO BLVD
Practice Address - Street 2:APT 308
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-8622
Practice Address - Country:US
Practice Address - Phone:954-801-5042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-22
Last Update Date:2016-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9319759363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily