1174871750 NPI number — IVY GRACE DURANT M.S.

Table of content: IVY GRACE DURANT M.S. (NPI 1174871750)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174871750 NPI number — IVY GRACE DURANT M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DURANT
Provider First Name:
IVY GRACE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174871750
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10652 SW 6TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33025-6907
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18999 BISCAYNE BLVD
Provider Second Line Business Practice Location Address:
#200
Provider Business Practice Location Address City Name:
AVENTURA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33180-2814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-933-9820
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/29/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)