Provider Demographics
NPI:1679199905
Name:LEE, IVY (PMHNP)
Entity Type:Individual
Prefix:MS
First Name:IVY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8530 NW 47TH ST
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3407
Mailing Address - Country:US
Mailing Address - Phone:954-654-1741
Mailing Address - Fax:
Practice Address - Street 1:7420 DWELL WELL WAY APT 1302
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-8930
Practice Address - Country:US
Practice Address - Phone:954-654-1741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9488738363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty