Provider Demographics
NPI:1710585617
Name:IVY HEALTHCARE
Entity Type:Organization
Organization Name:IVY HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SHEILA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRINKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:903-918-8520
Mailing Address - Street 1:PO BOX 6059
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75608-6059
Mailing Address - Country:US
Mailing Address - Phone:903-918-8520
Mailing Address - Fax:866-842-1649
Practice Address - Street 1:1100 N 4TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-4739
Practice Address - Country:US
Practice Address - Phone:903-918-8520
Practice Address - Fax:866-842-1649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-13
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP140963OtherLICENSE TO PRACTICE