Provider Demographics
NPI:1225025273
Name:IRISH, VICKI MARIE (NP(WOMEN'S HEALTH))
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:MARIE
Last Name:IRISH
Suffix:
Gender:F
Credentials:NP(WOMEN'S HEALTH)
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:K-9 UROLOGY
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:K-9 UROLOGY
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2062
Practice Address - Fax:313-916-8869
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024168785363LW0102X
MI4704208777363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health