Provider Demographics
NPI:1265118566
Name:LEE, IVY (RN)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7001 JOHNNYCAKE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WINDSOR MILL
Mailing Address - State:MD
Mailing Address - Zip Code:21244-2419
Mailing Address - Country:US
Mailing Address - Phone:443-522-0064
Mailing Address - Fax:
Practice Address - Street 1:7001 JOHNNYCAKE RD STE 101
Practice Address - Street 2:
Practice Address - City:WINDSOR MILL
Practice Address - State:MD
Practice Address - Zip Code:21244-2419
Practice Address - Country:US
Practice Address - Phone:443-522-0064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-22
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR169873163WM1400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM1400XNursing Service ProvidersRegistered NurseNurse Massage Therapist (NMT)