Provider Demographics
NPI:1871099044
Name:IRVIN, DEIDRA (FNP-C)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:IRVIN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2412 RING RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-5912
Mailing Address - Country:US
Mailing Address - Phone:270-769-2273
Mailing Address - Fax:
Practice Address - Street 1:2412 RING RD STE 100
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-5912
Practice Address - Country:US
Practice Address - Phone:270-769-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012243363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily