Provider Demographics
NPI:1417061029
Name:DETVILER, IRENE CAROLYN (RN)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:CAROLYN
Last Name:DETVILER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7806 IRISH AVE S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-2072
Mailing Address - Country:US
Mailing Address - Phone:651-459-2596
Mailing Address - Fax:
Practice Address - Street 1:255 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2572
Practice Address - Country:US
Practice Address - Phone:651-292-0616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR068147-4163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse