Provider Demographics
NPI:1750516142
Name:IVY, NINA MARIA (STNA)
Entity type:Individual
Prefix:MISS
First Name:NINA
Middle Name:MARIA
Last Name:IVY
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1293 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-5311
Mailing Address - Country:US
Mailing Address - Phone:937-430-0953
Mailing Address - Fax:937-372-8840
Practice Address - Street 1:1293 ARLINGTON DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-5311
Practice Address - Country:US
Practice Address - Phone:937-430-0953
Practice Address - Fax:937-372-8840
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH321040180900376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2862111Medicaid