Provider Demographics
NPI:1649754375
Name:MERRIMAN, IVY LEE (CRNA)
Entity Type:Individual
Prefix:
First Name:IVY
Middle Name:LEE
Last Name:MERRIMAN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2832 CRESTLINE RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5081
Mailing Address - Country:US
Mailing Address - Phone:229-254-0732
Mailing Address - Fax:
Practice Address - Street 1:1300 MICCOSUKEE RD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5054
Practice Address - Country:US
Practice Address - Phone:850-431-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL11001028367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program