Provider Demographics
NPI:1417403973
Name:IRWIN, KATHY (LPN)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:IRWIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:FAYSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4306 HUNTERS TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43607-2126
Mailing Address - Country:US
Mailing Address - Phone:419-360-8984
Mailing Address - Fax:
Practice Address - Street 1:3170 W CENTRAL AVE STE B
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-2945
Practice Address - Country:US
Practice Address - Phone:567-316-7253
Practice Address - Fax:567-316-7232
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140623164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0405434Medicaid