Provider Demographics
NPI:1003640319
Name:IVORY WELLNESS PLLC
Entity type:Organization
Organization Name:IVORY WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNDER
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRZYBYLA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:708-790-1952
Mailing Address - Street 1:400 LATHROP AVE STE 95
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1869
Mailing Address - Country:US
Mailing Address - Phone:708-724-9255
Mailing Address - Fax:
Practice Address - Street 1:400 LATHROP AVE STE 95
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1869
Practice Address - Country:US
Practice Address - Phone:708-724-9255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-28
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service