Provider Demographics
NPI:1629650163
Name:ALLEN, IVY
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:ALLEN
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 1:26460 MAPLERIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-2205
Mailing Address - Country:US
Mailing Address - Phone:951-363-8099
Mailing Address - Fax:
Practice Address - Street 1:26460 MAPLERIDGE WAY
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-2205
Practice Address - Country:US
Practice Address - Phone:951-363-8099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-24
Last Update Date:2021-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider