Healthcare Provider Details

I. General information

NPI: 1013661750
Provider Name (Legal Business Name): HALEY ITEN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

432 W 11TH AVE
EUGENE OR
97401-3451
US

IV. Provider business mailing address

432 W 11TH AVE
EUGENE OR
97401-3451
US

V. Phone/Fax

Practice location:
  • Phone: 541-662-4464
  • Fax:
Mailing address:
  • Phone: 541-662-4464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number201608628LPN
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier1689053688
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: