Provider Demographics
NPI:1437380169
Name:SMOTHERS, IVY LONDON (FNP-C)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:LONDON
Last Name:SMOTHERS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 MARIAN LN
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-2867
Mailing Address - Country:US
Mailing Address - Phone:601-831-7544
Mailing Address - Fax:
Practice Address - Street 1:1000 ASU DR
Practice Address - Street 2:
Practice Address - City:LORMAN
Practice Address - State:MS
Practice Address - Zip Code:39096-7510
Practice Address - Country:US
Practice Address - Phone:601-877-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSF07210326363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily