Provider Demographics
NPI:1255921987
Name:PRUSS, IVY
Entity type:Individual
Prefix:DR
First Name:IVY
Middle Name:
Last Name:PRUSS
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 1:1402 S PARK LOOP RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-9500
Mailing Address - Country:US
Mailing Address - Phone:307-690-7603
Mailing Address - Fax:
Practice Address - Street 1:1402 S PARK LOOP RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-9500
Practice Address - Country:US
Practice Address - Phone:307-690-7603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath