Healthcare Provider Details

I. General information

NPI: 1811775976
Provider Name (Legal Business Name): IRINA VESOLOWSKI FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

712 JAY ST
FOSSIL OR
97830-8371
US

IV. Provider business mailing address

7518 ORIENT AVE
KANSAS CITY KS
66112-2832
US

V. Phone/Fax

Practice location:
  • Phone: 541-763-2725
  • Fax: 541-763-2850
Mailing address:
  • Phone: 407-868-7515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11025518
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10015616
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: