Provider Demographics
NPI:1801371471
Name:WADDELL, IVORY
Entity Type:Individual
Prefix:
First Name:IVORY
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:BELLWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60104-2232
Mailing Address - Country:US
Mailing Address - Phone:708-544-5677
Mailing Address - Fax:
Practice Address - Street 1:3220 ADAMS ST
Practice Address - Street 2:
Practice Address - City:BELLWOOD
Practice Address - State:IL
Practice Address - Zip Code:60104-2232
Practice Address - Country:US
Practice Address - Phone:708-544-5677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-30
Last Update Date:2018-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILD14138856251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid