Provider Demographics
NPI:1821376104
Name:SCOVILL, ILISE M (RM)
Entity Type:Individual
Prefix:
First Name:ILISE
Middle Name:M
Last Name:SCOVILL
Suffix:
Gender:F
Credentials:RM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19029 E PLAZA DRIVE
Mailing Address - Street 2:SUITE 252
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134
Mailing Address - Country:US
Mailing Address - Phone:720-319-0709
Mailing Address - Fax:720-897-2882
Practice Address - Street 1:19029 E PLAZA DR
Practice Address - Street 2:SUITE 252
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-4018
Practice Address - Country:US
Practice Address - Phone:720-319-0709
Practice Address - Fax:720-897-2882
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO28176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife