Provider Demographics
NPI:1952801789
Name:IBARRA, JOVANNY
Entity Type:Individual
Prefix:
First Name:JOVANNY
Middle Name:
Last Name:IBARRA
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 1:4001 DILLARD CT
Mailing Address - Street 2:
Mailing Address - City:JOSHUA
Mailing Address - State:TX
Mailing Address - Zip Code:76058-5813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 DILLARD CT
Practice Address - Street 2:
Practice Address - City:JOSHUA
Practice Address - State:TX
Practice Address - Zip Code:76058-5813
Practice Address - Country:US
Practice Address - Phone:817-226-0262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX321984164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse