Provider Demographics
NPI:1124161765
Name:IRVIN, ANGELA R (ARNP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:R
Last Name:IRVIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 E BROADWAY
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1785
Mailing Address - Country:US
Mailing Address - Phone:502-217-8221
Mailing Address - Fax:502-217-5056
Practice Address - Street 1:215 CENTRAL AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40208-1418
Practice Address - Country:US
Practice Address - Phone:502-852-7449
Practice Address - Fax:502-852-1423
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY4734P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78018280Medicaid
IN200861110Medicaid
KY78018280Medicaid
KY0631256Medicare PIN
KY00243004Medicare PIN