Provider Demographics
NPI:1457648669
Name:LINDBLOM, IRINA (CNP)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:LINDBLOM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 STEPHENSON HWY
Mailing Address - Street 2:SUITE 400-CREDENTIALING DEPT
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1189
Mailing Address - Country:US
Mailing Address - Phone:313-745-4525
Mailing Address - Fax:313-993-0085
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:UHC 5A
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-4525
Practice Address - Fax:313-993-0085
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704217349363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P32180057Medicare PIN