1689865271 NPI number — KRISTINE MARIE DILLON PNP

Table of content: KRISTINE MARIE DILLON PNP (NPI 1689865271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689865271 NPI number — KRISTINE MARIE DILLON PNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DILLON
Provider First Name:
KRISTINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PNP
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:
1689865271
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
21515 SW RAMBLIN RECK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERWOOD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97140-9613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-625-6930
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1510 DIVISION ST
Provider Second Line Business Practice Location Address:
SUITE 280
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-1581
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-905-3400
Provider Business Practice Location Address Fax Number:
503-905-3399
Provider Enumeration Date:
08/07/2007

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: 363LP0200X , with the licence number:  077039035N2 , 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: 070222 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com