Basic Information
| Provider Information | |||||||||
| NPI: | 1306203393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARD | ||||||||
| FirstName: | IVA | ||||||||
| MiddleName: | DARKINA | ||||||||
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| Credential: | MS, LAT, ATC | ||||||||
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| OtherLastName: | WARD | ||||||||
| OtherFirstName: | IVA | ||||||||
| OtherMiddleName: | DARKINA | ||||||||
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| OtherCredential: | MS, LAT,ATC | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2011 GLENGATE CIR | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275606967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433856415 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | WILLIAM B AYCOCK BUILDING | ||||||||
| Address2: | 590 MANNING DRIVE , CAMPUS BOX 7595 | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275990001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9849842257 | ||||||||
| FaxNumber: | 9199666126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2016 | ||||||||
| LastUpdateDate: | 01/21/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | LAT-1653 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
ID Information
| ID | Type | State | Issuer | Description | LAT-1653 | 01 | NC | LICENCED ATHLETIC TRAINER | OTHER | 2000000710 | 01 | NC | ATHLETIC TRANIER CARTIFIED | OTHER |