Provider Demographics
NPI:1649220104
Name:IVY, ANDREA E (NP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:E
Last Name:IVY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12800 BOENKER LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2438
Mailing Address - Country:US
Mailing Address - Phone:314-551-0338
Mailing Address - Fax:314-551-0336
Practice Address - Street 1:12800 BOENKER LN
Practice Address - Street 2:
Practice Address - City:BRIDGETON
Practice Address - State:MO
Practice Address - Zip Code:63044-2438
Practice Address - Country:US
Practice Address - Phone:314-551-0338
Practice Address - Fax:314-551-0336
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137743363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429398209Medicaid
MOS39000003Medicare PIN
MOMA1084002Medicare PIN
MO000013853Medicare PIN
MO822223853Medicare PIN
MOQ27494Medicare UPIN