Healthcare Provider Details

I. General information

NPI: 1962236760
Provider Name (Legal Business Name): MARY CHRISTINE VRONTAKIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARY CHRISTINE VRONTAKIS RN

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12350 SW HARLEQUIN DR
BEAVERTON OR
97007-6237
US

IV. Provider business mailing address

12350 SW HARLEQUIN DR
BEAVERTON OR
97007-6237
US

V. Phone/Fax

Practice location:
  • Phone: 503-828-4254
  • Fax:
Mailing address:
  • Phone: 503-828-4254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number200142018RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: