Provider Demographics
NPI:1669022307
Name:NYIRENDA, IVANA (PA)
Entity Type:Individual
Prefix:
First Name:IVANA
Middle Name:
Last Name:NYIRENDA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 SHAFFER ST STE 108
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1629
Mailing Address - Country:US
Mailing Address - Phone:269-226-5967
Mailing Address - Fax:
Practice Address - Street 1:1717 SHAFFER ST STE 108
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1629
Practice Address - Country:US
Practice Address - Phone:269-226-5967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-15
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009532APP19207R00000X
MI5601009532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine