1033176532 NPI number — MS. JOANNE D IRVIN FNP

Table of content: MS. JOANNE D IRVIN FNP (NPI 1033176532)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033176532 NPI number — MS. JOANNE D IRVIN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRVIN
Provider First Name:
JOANNE
Provider Middle Name:
D
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DIFFLEY-CANNIFF
Provider Other First Name:
JOANNE
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1033176532
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 850
Provider Second Line Business Mailing Address:
ATTN WANDA BROWN CREDENTIALING
Provider Business Mailing Address City Name:
ROGERSVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37857-0850
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-272-9163
Provider Business Mailing Address Fax Number:
423-921-6920

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4966 HIGHWAY 11W
Provider Second Line Business Practice Location Address:
HAWKINS MEDICAL CENTER
Provider Business Practice Location Address City Name:
ROGERSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37857
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-272-5600
Provider Business Practice Location Address Fax Number:
423-272-1428
Provider Enumeration Date:
04/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  11979 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3643282 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4124843 . This is a "BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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