MEDICARE: WILLOW WOMEN AND CHILDREN'S WELLNESS, LLC

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	261QH0100X	Health Service Clinic/Center
2	363L00000X	Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	150392091	OTHER	OR	CORPORATION DIVISION FILLING IN OREGON

General Provider Information

NPI Number	:	1588136840
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW WOMEN AND CHILDREN'S WELLNESS, LLC

Provider Business Mailing Address
First Line	:	21358 HIGHWAY 99E NE
Second Line	:
City	:	AURORA
State	:	OR
Zip	:	97002-9201
Country	:	US
Telephone Number	:	503-678-6269
Fax Number	:	503-217-1599

Provider Business Practice Location Address
First Line	:	5665 WILSHIRE BLVD STE 1609
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90036-3710
Country	:	US
Telephone Number	:	424-600-8360
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SUSAN CORCORAN
Credential	:
Telephone Number	:	503-678-6269

Provider Enumeration Date	:	12/27/2018
Last Update Date	:	05/13/2025

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