1417095241 NPI number — MRS. SHERYL ROSALES MOREN PMHNP

Table of content: MRS. SHERYL ROSALES MOREN PMHNP (NPI 1417095241)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417095241 NPI number — MRS. SHERYL ROSALES MOREN PMHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOREN
Provider First Name:
SHERYL
Provider Middle Name:
ROSALES
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PMHNP
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:
1417095241
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4207 SE WOODSTOCK BLVD # 286
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:
97206-6267
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-714-6481
Provider Business Mailing Address Fax Number:
503-894-7972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2029 SE JEFFERSON ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
MILWAUKIE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97222-7605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-714-6481
Provider Business Practice Location Address Fax Number:
503-894-7972
Provider Enumeration Date:
02/02/2007

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: 163W00000X , with the licence number:  200241621RN , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0808X , with the licence number: 200450025NP PMHNP-PP , 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: 025187 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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