Basic Information
| Provider Information | |||||||||
| NPI: | 1477602043 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRVIN | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JONES | ||||||||
| OtherFirstName: | SANDRA | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1080 | ||||||||
| Address2: | |||||||||
| City: | BURKESVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427171080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708641472 | ||||||||
| FaxNumber: | 2708641693 | ||||||||
| Practice Location | |||||||||
| Address1: | 937 CAMPBELLSVILLE RD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | KY | ||||||||
| PostalCode: | 427282265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2703842777 | ||||||||
| FaxNumber: | 2703842770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3004654 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 78015112 | 05 | KY | MEDICAID |