MEDICARE: LISA MARY CHILDS PMHNP

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	95024758	CA
2	163W00000X	Registered Nurse	086006969	OR
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	10052894	OR
4	163W00000X	Registered Nurse	403624	CA

General Provider Information

NPI Number	:	1851073464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MARY CHILDS PMHNP

Provider Business Mailing Address
First Line	:	12655 SW CENTER ST STE 150
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97005-1864
Country	:	US
Telephone Number	:	503-832-0945
Fax Number	:

Provider Business Practice Location Address
First Line	:	12655 SW CENTER ST STE 150
Second Line	:
City	:	BEAVERTON
State	:	OR
Zip	:	97005-1864
Country	:	US
Telephone Number	:	503-832-0945
Fax Number	:

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

Provider Enumeration Date	:	08/02/2023
Last Update Date	:	02/06/2026

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