Provider Demographics
NPI:1942902663
Name:IVERY, SHANIQUE
Entity Type:Individual
Prefix:
First Name:SHANIQUE
Middle Name:
Last Name:IVERY
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 1:10333 CLAY RD APT 1011
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-2361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10333 CLAY RD APT 1011
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77041-2361
Practice Address - Country:US
Practice Address - Phone:832-726-5272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF421629-01363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health