Healthcare Provider Details

I. General information

NPI: 1417422551
Provider Name (Legal Business Name): KATELYN BROOKE ELLIOTT RN, WHNP, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2018
Last Update Date: 09/06/2022
Certification Date: 09/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12220 SW 1ST ST STE 200
BEAVERTON OR
97005-2890
US

IV. Provider business mailing address

12220 SW 1ST ST STE 200
BEAVERTON OR
97005-2890
US

V. Phone/Fax

Practice location:
  • Phone: 888-875-7820
  • Fax:
Mailing address:
  • Phone: 949-636-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number202207585NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: