Provider Demographics
NPI:1891178513
Name:IVERS, KATHLEEN DAWN (FNP-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:DAWN
Last Name:IVERS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:DAWN
Other - Last Name:SCELZO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5501 N 19TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2451
Mailing Address - Country:US
Mailing Address - Phone:602-589-0500
Mailing Address - Fax:602-314-4552
Practice Address - Street 1:5501 N 19TH AVE STE 103
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2451
Practice Address - Country:US
Practice Address - Phone:602-589-0500
Practice Address - Fax:602-314-4552
Is Sole Proprietor?:No
Enumeration Date:2015-06-30
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7926363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ086118Medicaid