Provider Demographics
NPI:1639103153
Name:HOOVER, IRENE T (NP)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:T
Last Name:HOOVER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6435 W JEFFERSON BLVD PMB 109
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-6203
Mailing Address - Country:US
Mailing Address - Phone:260-344-4035
Mailing Address - Fax:260-969-9272
Practice Address - Street 1:2200 RANDALLIA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4638
Practice Address - Country:US
Practice Address - Phone:260-344-4035
Practice Address - Fax:260-969-9272
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001646A363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200511080Medicaid
INP00968541OtherRR MEDICARE
P00968538OtherRR MEDICARE
IN217510DMedicare PIN
P00968538OtherRR MEDICARE
IN169380035Medicare PIN
INP00968541OtherRR MEDICARE
IN565800016Medicare PIN
INM400048556Medicare PIN
IN208790EEMedicare PIN