Healthcare Provider Details

I. General information

NPI: 1912540980
Provider Name (Legal Business Name): KYLE EDWARD ANDERSON PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12655 SW CENTER ST STE 150
BEAVERTON OR
97005-1864
US

IV. Provider business mailing address

1410 NE 106TH AVE
PORTLAND OR
97220-3934
US

V. Phone/Fax

Practice location:
  • Phone: 503-832-0945
  • Fax:
Mailing address:
  • Phone: 210-289-5953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP143637
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202007455NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: