Healthcare Provider Details

I. General information

NPI: 1336735380
Provider Name (Legal Business Name): MEHAMA ELIZABETH KAUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/14/2020
Certification Date: 12/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 NE COURTNEY DR
BEND OR
97701-7636
US

IV. Provider business mailing address

639 NW GEORGIA AVE
BEND OR
97703-3240
US

V. Phone/Fax

Practice location:
  • Phone: 541-647-5200
  • Fax:
Mailing address:
  • Phone: 541-639-7881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201604835RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: