Healthcare Provider Details

I. General information

NPI: 1104223247
Provider Name (Legal Business Name): INEKA K IRISH CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 01/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 JOHN R ST
DETROIT MI
48201-2018
US

IV. Provider business mailing address

1852 ROSEMONT RD
BERKLEY MI
48072-1846
US

V. Phone/Fax

Practice location:
  • Phone: 734-634-0931
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704276543
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: