Healthcare Provider Details

I. General information

NPI: 1063507762
Provider Name (Legal Business Name): JOANNE M O'BRIEN CFNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 MELTON RD
CRESWELL OR
97426
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT 358
VANCOUVER WA
98683-8004
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-7700
  • Fax: 541-895-5426
Mailing address:
  • Phone: 360-729-1253
  • Fax: 360-729-3185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201602228NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number48178
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.07283.NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: