Provider Demographics
NPI:1346810793
Name:LY, VI (DNP, CRNA)
Entity Type:Individual
Prefix:
First Name:VI
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4983 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763-6433
Mailing Address - Country:US
Mailing Address - Phone:909-630-8038
Mailing Address - Fax:
Practice Address - Street 1:525 N WOLFE ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21205-2110
Practice Address - Country:US
Practice Address - Phone:410-955-4766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR242988163W00000X
CA95002110367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse