Provider Demographics
NPI:1629434691
Name:ZICCARELLI, IVY LANE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:IVY
Middle Name:LANE
Last Name:ZICCARELLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1261
Mailing Address - Fax:704-384-3145
Practice Address - Street 1:1401 MATTHEWS TOWNSHIP PKWY STE 320
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105
Practice Address - Country:US
Practice Address - Phone:704-384-1261
Practice Address - Fax:704-384-3145
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363AM0700X
NC0010-06261363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical