Healthcare Provider Details

I. General information

NPI: 1639384951
Provider Name (Legal Business Name): GENA DELL GRANBERG F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9775 SE SUNNYSIDE RD SUITE 200
CLACKAMAS OR
97015-5739
US

IV. Provider business mailing address

15914 NE 16TH CIR
VANCOUVER WA
98684-4130
US

V. Phone/Fax

Practice location:
  • Phone: 503-654-8417
  • Fax: 503-654-8218
Mailing address:
  • Phone: 360-944-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: