Provider Demographics
NPI:1598827651
Name:KOLBERG, IRENE (NP)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:KOLBERG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 SUMMIT AVE
Mailing Address - Street 2:FAIN 3RD FLOOR
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-2853
Mailing Address - Country:US
Mailing Address - Phone:401-793-2920
Mailing Address - Fax:401-793-2859
Practice Address - Street 1:164 SUMMIT AVE
Practice Address - Street 2:FAIN 3RD FLOOR
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-2853
Practice Address - Country:US
Practice Address - Phone:401-793-2920
Practice Address - Fax:401-793-2859
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RINPP00149363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner