Provider Demographics
NPI:1962659433
Name:IVY, LAURA LYNN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:IVY
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 1:408 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-3017
Mailing Address - Country:US
Mailing Address - Phone:501-362-2525
Mailing Address - Fax:501-362-2751
Practice Address - Street 1:408 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-3017
Practice Address - Country:US
Practice Address - Phone:501-362-2525
Practice Address - Fax:501-362-2751
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR3072225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist