Basic Information
Provider Information
NPI: 1679756787
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FORREST
FirstName: IRENE
MiddleName: LYNETTE
NamePrefix: MS.
NameSuffix:  
Credential: ARNP-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 13000 BRUCE B DOWNS BLVD
Address2:  
City: TAMPA
State: FL
PostalCode: 336124745
CountryCode: US
TelephoneNumber: 8139722000
FaxNumber:  
Practice Location
Address1: 340 S WILLARD ST
Address2:  
City: COTTONWOOD
State: AZ
PostalCode: 863264126
CountryCode: US
TelephoneNumber: 9286396025
FaxNumber: 9286346504
Other Information
ProviderEnumerationDate: 12/11/2007
LastUpdateDate: 09/08/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 09/08/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363L00000X2775872FLN Physician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 
363L00000XAP4370AZY Physician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 

ID Information
IDTypeStateIssuerDescription
30887660005FL MEDICAID


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