1922090232 NPI number — KAREN ANN RYDELL RN, ANP

Table of content: KAREN ANN RYDELL RN, ANP (NPI 1922090232)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922090232 NPI number — KAREN ANN RYDELL RN, ANP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RYDELL
Provider First Name:
KAREN
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, ANP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RYDELL
Provider Other First Name:
KAREN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN, ANP
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1922090232
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1111 NE 99TH AVE
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97220-9442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-962-1000
Provider Business Mailing Address Fax Number:
503-962-1005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6350 NE HALSEY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97213-4720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-215-2669
Provider Business Practice Location Address Fax Number:
503-215-8465
Provider Enumeration Date:
08/22/2005

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: 363LA2200X , with the licence number:  086000043N3 ANP , 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: 291783 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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