Healthcare Provider Details

I. General information

NPI: 1265977607
Provider Name (Legal Business Name): MYLENE ENID ROBINSON THW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2016
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 NW SPRINGHILL DR
ALBANY OR
97321-1748
US

IV. Provider business mailing address

911 E GRANT ST
LEBANON OR
97355-4400
US

V. Phone/Fax

Practice location:
  • Phone: 352-874-5803
  • Fax:
Mailing address:
  • Phone: 352-874-5803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberTHW1507
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: