MEDICARE: LISA ANNE HEREDIA NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	10055637	OR

General Provider Information

NPI Number	:	1386503233
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ANNE HEREDIA NP

Provider Business Mailing Address
First Line	:	480 5TH ST STE 101
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97034-3079
Country	:	US
Telephone Number	:	503-267-8041
Fax Number	:

Provider Business Practice Location Address
First Line	:	480 5TH ST STE 101
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97034-3079
Country	:	US
Telephone Number	:	503-267-8041
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2026
Last Update Date	:	01/18/2026

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