Provider Demographics
NPI:1689176885
Name:IVORY, TIA ROCHE (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:TIA
Middle Name:ROCHE
Last Name:IVORY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019A SOUTH HENDERSON BLVD, SUITE 2
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-3915
Mailing Address - Country:US
Mailing Address - Phone:903-483-7707
Mailing Address - Fax:903-483-7708
Practice Address - Street 1:2019A S HENDERSON BLVD STE 2
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-3567
Practice Address - Country:US
Practice Address - Phone:903-483-7707
Practice Address - Fax:903-483-7708
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-03
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136828363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8025511OtherAETNA