Basic Information
| Provider Information | |||||||||
| NPI: | 1366944837 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IVIE | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | LEE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1037 16TH STREET | ||||||||
| Address2: | |||||||||
| City: | WYANDOTTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487871768 | ||||||||
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| Practice Location | |||||||||
| Address1: | 26650 EUREKA RD SUITE C | ||||||||
| Address2: | |||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349414991 | ||||||||
| FaxNumber: | 7349414919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2018 | ||||||||
| LastUpdateDate: | 03/01/2018 | ||||||||
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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 | 363LG0600X | 4704248024 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LA2200X | 4704248024 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.