Provider Demographics
NPI:1679756787
Name:FORREST, IRENE LYNETTE (ARNP-C)
Entity Type:Individual
Prefix:MS
First Name:IRENE
Middle Name:LYNETTE
Last Name:FORREST
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13000 BRUCE B DOWNS BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-4745
Mailing Address - Country:US
Mailing Address - Phone:813-972-2000
Mailing Address - Fax:
Practice Address - Street 1:340 S WILLARD ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4126
Practice Address - Country:US
Practice Address - Phone:928-639-6025
Practice Address - Fax:928-634-6504
Is Sole Proprietor?:No
Enumeration Date:2007-12-11
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2775872363L00000X
AZAP4370363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308876600Medicaid
FL308876600Medicaid