Healthcare Provider Details

I. General information

NPI: 1912279142
Provider Name (Legal Business Name): KIMBERLY ANN PETROS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 02/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12350 SW 5TH ST STE 100
BEAVERTON OR
97005-2819
US

IV. Provider business mailing address

12350 SW 5TH ST STE 100
BEAVERTON OR
97005-2819
US

V. Phone/Fax

Practice location:
  • Phone: 503-627-9194
  • Fax:
Mailing address:
  • Phone: 503-627-9194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: