Provider Demographics
NPI:1568979748
Name:IVEY, CARALYN WILKERSON (FNP)
Entity Type:Individual
Prefix:
First Name:CARALYN
Middle Name:WILKERSON
Last Name:IVEY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19420 GOLF VISTA PLZ STE 240
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-8267
Mailing Address - Country:US
Mailing Address - Phone:703-444-6544
Mailing Address - Fax:
Practice Address - Street 1:19420 GOLF VISTA PLZ STE 240
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-8267
Practice Address - Country:US
Practice Address - Phone:703-444-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-09
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015024036163WS0200X
VA0024181358363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WS0200XNursing Service ProvidersRegistered NurseSchool