1477602043 NPI number — SANDRA KAY IRVIN ARNP

Table of content: SANDRA KAY IRVIN ARNP (NPI 1477602043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477602043 NPI number — SANDRA KAY IRVIN ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IRVIN
Provider First Name:
SANDRA
Provider Middle Name:
KAY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JONES
Provider Other First Name:
SANDRA
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477602043
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1080
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURKESVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42717-1080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-864-1472
Provider Business Mailing Address Fax Number:
270-864-1693

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
937 CAMPBELLSVILLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42728-2265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-384-2777
Provider Business Practice Location Address Fax Number:
270-384-2770
Provider Enumeration Date:
01/10/2007

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: 363LF0000X , with the licence number:  3004654 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 78015112 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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