Basic Information
| Provider Information | |||||||||
| NPI: | 1073061420 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MCIVOR | ||||||||
| FirstName: | CARRIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 262 DANNY THOMAS PL | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381053678 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 262 DANNY THOMAS PL | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381053678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015953300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2016 | ||||||||
| LastUpdateDate: | 09/14/2016 | ||||||||
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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 | 363LP0200X | 21435 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.