Provider Demographics
NPI:1811355845
Name:IVEY, TEQUILA (LPN)
Entity type:Individual
Prefix:
First Name:TEQUILA
Middle Name:
Last Name:IVEY
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 1:1038 PLYMOUTH AVE S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-2941
Mailing Address - Country:US
Mailing Address - Phone:585-503-6255
Mailing Address - Fax:
Practice Address - Street 1:1038 PLYMOUTH AVE S
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-2941
Practice Address - Country:US
Practice Address - Phone:585-503-6255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY316825164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse