Healthcare Provider Details

I. General information

NPI: 1053895110
Provider Name (Legal Business Name): RENAE RYKACZEWSKI FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST STE 300
GRESHAM OR
97030-7318
US

IV. Provider business mailing address

6120 N CONCORD AVE
PORTLAND OR
97217-4735
US

V. Phone/Fax

Practice location:
  • Phone: 530-988-5155
  • Fax:
Mailing address:
  • Phone: 323-580-9119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201807432NP-PP
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier1053895110
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: