Healthcare Provider Details

I. General information

NPI: 1104437011
Provider Name (Legal Business Name): WENDY WAIBEL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21015 SE STARK ST
GRESHAM OR
97030-2015
US

IV. Provider business mailing address

21015 SE STARK ST
GRESHAM OR
97030-2015
US

V. Phone/Fax

Practice location:
  • Phone: 503-669-6120
  • Fax: 503-669-6163
Mailing address:
  • Phone: 503-669-6120
  • Fax: 503-669-6163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202214629NP-PP
License Number StateOR

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: