Provider Demographics
NPI:1114203767
Name:IRORERE, ANN OSAMUDIAIMEN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:OSAMUDIAIMEN
Last Name:IRORERE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 SOUTH LEYDEN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302
Mailing Address - Country:US
Mailing Address - Phone:508-345-6313
Mailing Address - Fax:
Practice Address - Street 1:155 SOUTH LEYDEN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302
Practice Address - Country:US
Practice Address - Phone:508-345-6313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAN2257719363LA2200X
MARN2257719363LP0808X, 163W00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA163W00000XMedicaid