MEDICARE: AURORA LAKE ACNP

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	363LA2100X	Acute Care Nurse Practitioner	RN2291759	MA
2	363LG0600X	Gerontology Nurse Practitioner	RN2291759	MA
3	363LG0600X	Gerontology Nurse Practitioner	202001095NP-PP	OR
4	363LA2100X	Acute Care Nurse Practitioner	202001095NP-PP	OR

General Provider Information

NPI Number	:	1538609938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AURORA LAKE ACNP

Provider Business Mailing Address
First Line	:	720 HARRION AVE
Second Line	:	DOB 503
City	:	BOSTON
State	:	MA
Zip	:	02118-1207
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	335 SE 8TH AVE
Second Line	:
City	:	HILLSBORO
State	:	OR
Zip	:	97123-4248
Country	:	US
Telephone Number	:	503-681-1111
Fax Number	:	503-681-4066

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

Provider Enumeration Date	:	03/03/2017
Last Update Date	:	09/20/2024

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