Provider Demographics
NPI:1437631470
Name:MCIVOR, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:MCIVOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 ANNA DR
Mailing Address - Street 2:
Mailing Address - City:BOWMANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14026-1017
Mailing Address - Country:US
Mailing Address - Phone:716-331-6882
Mailing Address - Fax:
Practice Address - Street 1:9 ANNA DR
Practice Address - Street 2:
Practice Address - City:BOWMANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14026-1017
Practice Address - Country:US
Practice Address - Phone:716-331-6882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332059164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse