1265699508 NPI number — MS. MALLORY JOHNSON PEDIATRIC NP

Table of content: SANDRA WISEBAKER MD (NPI 1770530719)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265699508 NPI number — MS. MALLORY JOHNSON PEDIATRIC NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MALLORY
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
PEDIATRIC NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRAUN
Provider Other First Name:
MALLORY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PEDIATRIC NURSE PRAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1265699508
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11790 SW BARNES RD. BLG A
Provider Second Line Business Mailing Address:
STE 140
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-643-2100
Provider Business Mailing Address Fax Number:
503-643-7300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11790 SW BARNES RD. BLG A
Provider Second Line Business Practice Location Address:
STE 140
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-643-2100
Provider Business Practice Location Address Fax Number:
503-643-7300
Provider Enumeration Date:
05/22/2008

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: 363LP0200X , with the licence number:  200850163NP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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