Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363LA2200X | Nurse Practitioner - Adult Health | 4704279990 | MI |
N | 363LG0600X | Nurse Practitioner - Gerontology | 4704279990 | MI |
Y | 363LP2300X | Nurse Practitioner - Primary Care | 4704279990 | MI |
NPI | 1023409034 |
---|---|
Provider Name | Ivy Mckenzie Carson |
First Address | West Hollywood, CA 90069-4496 |
Second Address | West Hollywood, CA 90069-4496 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2015 |
Last Update Date | 30/11/2020 |