Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2100X | Nurse Practitioner - Acute Care | 60978206 | WA |
NPI | 1003463951 |
---|---|
Provider Name | Corene Kimberly Irvin |
First Address | Puyallup, WA 98375-8489 |
Second Address | Puyallup, WA 98375-8489 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/08/2019 |
Last Update Date | 01/11/2021 |