Healthcare Provider Details

I. General information

NPI: 1245164029
Provider Name (Legal Business Name): KORI LYNNE CARBONARO RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 NW WATERHOUSE AVE
BEAVERTON OR
97006-5747
US

IV. Provider business mailing address

1260 NW WATERHOUSE AVE
BEAVERTON OR
97006-5747
US

V. Phone/Fax

Practice location:
  • Phone: 503-356-2420
  • Fax: 503-356-2425
Mailing address:
  • Phone: 503-356-2420
  • Fax: 503-356-2425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number201390954RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: