Healthcare Provider Details

I. General information

NPI: 1346340361
Provider Name (Legal Business Name): JULIE A PROCTOR FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24800 SE STARK ST
GRESHAM OR
97030-3378
US

IV. Provider business mailing address

4233 SE 182ND AVE STE 362
GRESHAM OR
97030-5082
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-1122
  • Fax:
Mailing address:
  • Phone: 503-807-8006
  • Fax: 503-658-2864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200650016NP
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier000494
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: