Provider Demographics
NPI:1871726679
Name:DE LEON, IVY GERALYN (PMHNP-BC, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:IVY
Middle Name:GERALYN
Last Name:DE LEON
Suffix:
Gender:F
Credentials:PMHNP-BC, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BILLINSGATE CT
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6702
Mailing Address - Country:US
Mailing Address - Phone:704-880-1466
Mailing Address - Fax:704-880-1466
Practice Address - Street 1:378 WILLIAMSON RD STE 204
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-5917
Practice Address - Country:US
Practice Address - Phone:704-978-8334
Practice Address - Fax:980-399-2600
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC182897363LF0000X, 363LP0808X
NC5004501363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000658Medicaid
NC2594567DOtherMEDICARE PTAN, INDIVIDUAL
NC7000658Medicaid