Provider Demographics
NPI:1013919554
Name:DETTMER, IRENE E (CRNP)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:E
Last Name:DETTMER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1990 MAHONING RD
Mailing Address - Street 2:
Mailing Address - City:DEERFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44411-8735
Mailing Address - Country:US
Mailing Address - Phone:330-654-2646
Mailing Address - Fax:
Practice Address - Street 1:275 GRAHAM RD
Practice Address - Street 2:SUITE 4
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44223-2203
Practice Address - Country:US
Practice Address - Phone:330-926-9409
Practice Address - Fax:330-926-9428
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN 110530363L00000X, 363LA2200X
OHNP 04647363L00000X
OHNP04647363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH27YY61105006OtherMEDICAL MUTUAL
OH000000323216OtherBC BS
OH2096253Medicaid
OHNP02053Medicare ID - Type Unspecified
OH2096253Medicaid