Healthcare Provider Details

I. General information

NPI: 1629102272
Provider Name (Legal Business Name): STACEY L WILSON CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 04/29/2008
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

8646 NW SKYLINE BLVD
PORTLAND OR
97231-2618
US

V. Phone/Fax

Practice location:
  • Phone: 503-626-5515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberOR 200050017NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: