Provider Demographics
NPI:1649940552
Name:MILLS, IVY NICHELLE (LPN)
Entity type:Individual
Prefix:MS
First Name:IVY
Middle Name:NICHELLE
Last Name:MILLS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CLAYTON AVE
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13207-2106
Mailing Address - Country:US
Mailing Address - Phone:315-560-6236
Mailing Address - Fax:
Practice Address - Street 1:111 CLAYTON AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13207-2106
Practice Address - Country:US
Practice Address - Phone:315-560-6236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY328538-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse