1376888107 NPI number — BAILEY ANN OUELLETTE P.T.

Table of content: BAILEY ANN OUELLETTE P.T. (NPI 1376888107)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376888107 NPI number — BAILEY ANN OUELLETTE P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OUELLETTE
Provider First Name:
BAILEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1376888107
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16083 SW UPPER BOONES FERRY RD
Provider Second Line Business Mailing Address:
STE. 300
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97224-7736
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-219-8835
Provider Business Mailing Address Fax Number:
503-639-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13470 SW FARMINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAVERTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97005-2618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-644-3311
Provider Business Practice Location Address Fax Number:
503-627-0112
Provider Enumeration Date:
12/05/2012

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: 225100000X , with the licence number:  60037 , 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)

  • Identifier: 500652655 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01527068 . This is a "RR MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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