Provider Demographics
NPI:1083495980
Name:MAYBERRY, IRINA (APRN)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:MAYBERRY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 COTTONWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-4776
Mailing Address - Country:US
Mailing Address - Phone:731-707-1627
Mailing Address - Fax:
Practice Address - Street 1:138 COTTONWOOD CIR
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-4776
Practice Address - Country:US
Practice Address - Phone:731-707-1627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-09
Last Update Date:2023-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11029039363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner