Provider Demographics
NPI:1649647595
Name:IRVIN, CHIQUITA
Entity type:Individual
Prefix:
First Name:CHIQUITA
Middle Name:
Last Name:IRVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1949
Mailing Address - Country:US
Mailing Address - Phone:315-879-7780
Mailing Address - Fax:
Practice Address - Street 1:201 E MAPLE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1949
Practice Address - Country:US
Practice Address - Phone:315-879-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293157-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse