Provider Demographics
NPI:1205674025
Name:MICKEL, IVORY
Entity type:Individual
Prefix:
First Name:IVORY
Middle Name:
Last Name:MICKEL
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 1:2170 GREGORY AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44511-2206
Mailing Address - Country:US
Mailing Address - Phone:330-951-8909
Mailing Address - Fax:
Practice Address - Street 1:2170 GREGORY AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44511-2206
Practice Address - Country:US
Practice Address - Phone:330-951-8909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion