=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679707202
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE M IRWIN LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2009
-----------------------------------------------------
Last Update Date | 05/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42 LOG CABIN DR
-----------------------------------------------------
City | GRANTVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17028-8204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-469-0462
-----------------------------------------------------
Fax | 717-469-1406
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42 LOG CABIN DR
-----------------------------------------------------
City | GRANTVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17028-8204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 717-469-0462
-----------------------------------------------------
Fax | 717-469-1406
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MA34235
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------