Provider Demographics
NPI:1437650777
Name:IRVINE, WENDY (FPA, NYSPEP CPE LL)
Entity Type:Individual
Prefix:MS
First Name:WENDY
Middle Name:
Last Name:IRVINE
Suffix:
Gender:F
Credentials:FPA, NYSPEP CPE LL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N GOODMAN ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-1185
Mailing Address - Country:US
Mailing Address - Phone:585-325-3145
Mailing Address - Fax:585-325-3188
Practice Address - Street 1:320 N GOODMAN ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14607-1185
Practice Address - Country:US
Practice Address - Phone:585-325-3145
Practice Address - Fax:585-325-3188
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNYSCPS-1459175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYNYCPS-1459Medicaid