Provider Demographics
NPI:1245672294
Name:IVAN, COURTNEY LYNN (ATC, LAT)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LYNN
Last Name:IVAN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2699 LEE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-1738
Mailing Address - Country:US
Mailing Address - Phone:407-897-1363
Mailing Address - Fax:
Practice Address - Street 1:2699 LEE RD STE 100
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-1738
Practice Address - Country:US
Practice Address - Phone:407-897-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL33322255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer