Healthcare Provider Details

I. General information

NPI: 1912722331
Provider Name (Legal Business Name): FELICIA GWYN CAE, LE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 N MAIN AVE
GRESHAM OR
97030-7229
US

IV. Provider business mailing address

29320 SE WHEELER RD
BORING OR
97009-8428
US

V. Phone/Fax

Practice location:
  • Phone: 503-710-8333
  • Fax:
Mailing address:
  • Phone: 503-621-8995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156F00000X
TaxonomyTechnician/Technologist
License NumberBAP-E-10248793
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: