Provider Demographics
NPI:1689956195
Name:KASALLIS, IVY L (RN, MSN)
Entity Type:Individual
Prefix:MISS
First Name:IVY
Middle Name:L
Last Name:KASALLIS
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:
Other - Last Name:KASALLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2207 N WESTERN AVE APT 3A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4568
Mailing Address - Country:US
Mailing Address - Phone:607-327-3326
Mailing Address - Fax:
Practice Address - Street 1:1401 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3010
Practice Address - Country:US
Practice Address - Phone:213-748-2411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA669720163W00000X
CA95000114367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse