=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508205477
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IRENE DUSTIN CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2013
-----------------------------------------------------
Last Update Date | 06/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | NIH NINDS CES BLDG 10 7 5644 10 CENTER DRIVE
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20892-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-451-9284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | NIH NINDS CES BLDG 10 7 5644 10 CENTER DRIVE
-----------------------------------------------------
City | BETHESDA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20892-1408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-451-9284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | R114723
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------