1326812488 NPI number — ATHENA LEEANN WILDENBORG T-23-2498

Table of content: ATHENA LEEANN WILDENBORG T-23-2498 (NPI 1326812488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326812488 NPI number — ATHENA LEEANN WILDENBORG T-23-2498

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILDENBORG
Provider First Name:
ATHENA
Provider Middle Name:
LEEANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
T-23-2498
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:
1326812488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1122 NE 122ND AVE STE A102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97230-2082
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-954-1890
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 LA LOMA CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95678-2908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-214-4102
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/09/2023

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: 101Y00000X , with the licence number:  T-23-2498 , 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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