Healthcare Provider Details

I. General information

NPI: 1295083475
Provider Name (Legal Business Name): STACY LYN IRWIN ACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 SIXTH ST SW
CANTON OH
44710-1702
US

IV. Provider business mailing address

PO BOX 80690
CANTON OH
44708-0690
US

V. Phone/Fax

Practice location:
  • Phone: 330-363-2180
  • Fax: 330-363-2179
Mailing address:
  • Phone: 330-479-8705
  • Fax: 330-479-5440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCOA-13647-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: