Healthcare Provider Details

I. General information

NPI: 1720883697
Provider Name (Legal Business Name): LINA MELESE IYASSU PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2025
Last Update Date: 02/15/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4180 SE HILLYARD RD
GRESHAM OR
97080-7236
US

IV. Provider business mailing address

4180 SE HILLYARD RD
GRESHAM OR
97080-7236
US

V. Phone/Fax

Practice location:
  • Phone: 405-401-1149
  • Fax:
Mailing address:
  • Phone: 405-401-1149
  • Fax: 503-912-1608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number201805649RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: