Healthcare Provider Details

I. General information

NPI: 1326820218
Provider Name (Legal Business Name): HEATHER LEIGH IRVIN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2023
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

929 STACEY BURK DR
FLORA IL
62839-3241
US

IV. Provider business mailing address

945 BARBEE AVE
LOUISVILLE IL
62858-1070
US

V. Phone/Fax

Practice location:
  • Phone: 618-662-2131
  • Fax:
Mailing address:
  • Phone: 618-335-2096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209028427
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: