Provider Demographics
NPI:1386281962
Name:BORTNOVSKY, IRINA
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:BORTNOVSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7273 14TH AVE STE 120B
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-3500
Mailing Address - Country:US
Mailing Address - Phone:916-383-6783
Mailing Address - Fax:
Practice Address - Street 1:5228 COPPER RIDGE WAY
Practice Address - Street 2:
Practice Address - City:ANTELOPE
Practice Address - State:CA
Practice Address - Zip Code:95843-5984
Practice Address - Country:US
Practice Address - Phone:916-761-0454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA663089163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse