Provider Demographics
NPI:1790914711
Name:IVY, GREGORY LEE (RN)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEE
Last Name:IVY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 KOURT DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-2279
Mailing Address - Country:US
Mailing Address - Phone:541-514-4891
Mailing Address - Fax:866-669-7086
Practice Address - Street 1:615 KOURT DR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-2279
Practice Address - Country:US
Practice Address - Phone:541-514-4891
Practice Address - Fax:866-669-7086
Is Sole Proprietor?:No
Enumeration Date:2009-07-12
Last Update Date:2009-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR080044735RN163WH0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0500XNursing Service ProvidersRegistered NurseHemodialysis