Healthcare Provider Details

I. General information

NPI: 1881484962
Provider Name (Legal Business Name): ISREAL KIRK WAKEFIELD SR. PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2025
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 CORYDON RAMSEY RD NW STE 101
CORYDON IN
47112-2270
US

IV. Provider business mailing address

1345 CORYDON RAMSEY RD NW STE 101
CORYDON IN
47112-2270
US

V. Phone/Fax

Practice location:
  • Phone: 812-269-8577
  • Fax:
Mailing address:
  • Phone: 812-269-8577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number28193439A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: