Healthcare Provider Details

I. General information

NPI: 1861507279
Provider Name (Legal Business Name): MARYLYN R. KLESH PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3460
US

IV. Provider business mailing address

4855 SW WESTERN AVE
BEAVERTON OR
97005-3460
US

V. Phone/Fax

Practice location:
  • Phone: 503-643-7565
  • Fax:
Mailing address:
  • Phone: 503-249-3434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number000024615N6
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: