Provider Demographics
NPI:1063963627
Name:IRBY, TONI L (HAIR LOSS SPECIALIST)
Entity type:Individual
Prefix:
First Name:TONI
Middle Name:L
Last Name:IRBY
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 BUNKER HILL PL
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825
Mailing Address - Country:US
Mailing Address - Phone:260-760-6686
Mailing Address - Fax:
Practice Address - Street 1:3219 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805
Practice Address - Country:US
Practice Address - Phone:260-760-6686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INBC298008061744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management