Healthcare Provider Details

I. General information

NPI: 1639452006
Provider Name (Legal Business Name): BERTHA RENEE KIRWAN FNP, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

332 CONGRESS PARK DR
DAYTON OH
45459-4133
US

IV. Provider business mailing address

6845 WORTHINGTON GALENA RD
WORTHINGTON OH
43085-2645
US

V. Phone/Fax

Practice location:
  • Phone: 937-312-3627
  • Fax:
Mailing address:
  • Phone: 614-847-3891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12637
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: