Provider Demographics
NPI:1477602043
Name:IRVIN, SANDRA KAY (ARNP)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:KAY
Last Name:IRVIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:KAY
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 1080
Mailing Address - Street 2:
Mailing Address - City:BURKESVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42717-1080
Mailing Address - Country:US
Mailing Address - Phone:270-864-1472
Mailing Address - Fax:270-864-1693
Practice Address - Street 1:937 CAMPBELLSVILLE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:KY
Practice Address - Zip Code:42728-2265
Practice Address - Country:US
Practice Address - Phone:270-384-2777
Practice Address - Fax:270-384-2770
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004654363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78015112Medicaid
Q53192Medicare UPIN
KY78015112Medicaid
KY181861Medicare PIN
KY78015112Medicaid