Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 221578 | LA |
NPI | 1043986532 |
---|---|
Provider Name | Molly Mckay Ivy |
First Address | Austin, TX 78759-8728 |
Second Address | Alexandria, LA 71301-8421 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2021 |
Last Update Date | 17/08/2021 |