Healthcare Provider Details

I. General information

NPI: 1023877636
Provider Name (Legal Business Name): HILLARY DIANE DAVAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 08/17/2024
Certification Date: 08/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15455 NW GREENBRIER PKWY STE 111
BEAVERTON OR
97006-7357
US

IV. Provider business mailing address

5655 NE HIDDEN CREEK DR
HILLSBORO OR
97124-6116
US

V. Phone/Fax

Practice location:
  • Phone: 503-709-0008
  • Fax:
Mailing address:
  • Phone: 503-709-0008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number201604360RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number10030013
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: