Healthcare Provider Details

I. General information

NPI: 1861742025
Provider Name (Legal Business Name): MARYELLEN PARKER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2255 NW SHEVLIN PARK RD STE 110
BEND OR
97703-7134
US

IV. Provider business mailing address

1375 NW KINGSTON AVE
BEND OR
97701-2242
US

V. Phone/Fax

Practice location:
  • Phone: 541-728-2525
  • Fax: 503-917-4971
Mailing address:
  • Phone: 541-383-5958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22382
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201501459NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: