Healthcare Provider Details

I. General information

NPI: 1538627708
Provider Name (Legal Business Name): SARAH ROSE VONGDEUANE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25050 SE STARK ST STE 300
GRESHAM OR
97030-3388
US

IV. Provider business mailing address

200 SW MARKET ST STE 1650
PORTLAND OR
97201-5739
US

V. Phone/Fax

Practice location:
  • Phone: 503-917-5084
  • Fax:
Mailing address:
  • Phone: 503-917-5084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number115079
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: