Healthcare Provider Details

I. General information

NPI: 1124381306
Provider Name (Legal Business Name): MARIANNE WENGRIN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18870 SW ALOHA CT
BEAVERTON OR
97006
US

IV. Provider business mailing address

18870 S.W.ALOHA CT.
BAEVERTON OR
97006
US

V. Phone/Fax

Practice location:
  • Phone: 209-609-0931
  • Fax:
Mailing address:
  • Phone: 209-609-0931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number20124101RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: