Healthcare Provider Details

I. General information

NPI: 1629007182
Provider Name (Legal Business Name): LEONA MARIE ANDERSON DNP, AGPCNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date: 04/13/2019
Reactivation Date: 04/24/2019

III. Provider practice location address

101 1ST ST
GLENDALE OR
97442-9640
US

IV. Provider business mailing address

1843 STARVEOUT CREEK RD
AZALEA OR
97410-9701
US

V. Phone/Fax

Practice location:
  • Phone: 541-832-5400
  • Fax:
Mailing address:
  • Phone: 541-837-8374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN091484
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number201805000NPPP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: