1063507762 NPI number — JOANNE M O'BRIEN CFNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063507762 NPI number — JOANNE M O'BRIEN CFNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'BRIEN
Provider First Name:
JOANNE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CFNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063507762
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 SE 164TH AVE DEPT 358
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-8004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-729-1253
Provider Business Mailing Address Fax Number:
360-729-3185

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
180 MELTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESWELL
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-222-7700
Provider Business Practice Location Address Fax Number:
541-895-5426
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  201602228NP-PP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 48178 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: COA.07283.NP , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P01346092 . This is a "RAILROAD MEDICARE - MHCPI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 000000699826 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2398641 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3810011350 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 000000680676 . This is a "ANTHEM" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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