Healthcare Provider Details

I. General information

NPI: 1033707708
Provider Name (Legal Business Name): MONELLE LARISSA BURRUS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SW SCALEHOUSE LOOP UNIT 106
BEND OR
97702-1272
US

IV. Provider business mailing address

2645 NW SKY VISTA CT
BEND OR
97703-8604
US

V. Phone/Fax

Practice location:
  • Phone: 541-728-8262
  • Fax: 541-203-2202
Mailing address:
  • Phone: 541-728-8262
  • Fax: 541-203-2022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number202100185NP-PP
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: