Provider Demographics
NPI:1356088272
Name:DEEGAN, IVY ELIZABETH (CRNP)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:ELIZABETH
Last Name:DEEGAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:814-868-2507
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:4740 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2008
Practice Address - Country:US
Practice Address - Phone:814-454-3174
Practice Address - Fax:814-616-8002
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP025602363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN682711OtherMEDICAL LICENSE
PASP025602OtherMEDICAL LICENSE