Healthcare Provider Details

I. General information

NPI: 1013473297
Provider Name (Legal Business Name): PATRICIA JUSTINE IRVIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 10/29/2021
Certification Date: 10/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 US HIGHWAY 31 S
GREENWOOD IN
46143-2401
US

IV. Provider business mailing address

6626 E 75TH ST STE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-883-0567
  • Fax:
Mailing address:
  • Phone: 317-621-7547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number71008765A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: