Provider Demographics
NPI:1063575330
Name:IRISH, DONNA MARIE (APRN-BC, GNP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:IRISH
Suffix:
Gender:F
Credentials:APRN-BC, GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5087 S CLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2855
Mailing Address - Country:US
Mailing Address - Phone:417-885-0015
Mailing Address - Fax:
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-820-2936
Practice Address - Fax:417-820-7796
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN 152510363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO431560263149OtherTRICARE PROVIDER NUMBER
MORN152510OtherRN LICENSE
MO431560263149OtherTRICARE PROVIDER NUMBER