Healthcare Provider Details

I. General information

NPI: 1497954994
Provider Name (Legal Business Name): MARYELLEN HIBBARD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 NW COUNCIL DR SUITE 300
GRESHAM OR
97030-3721
US

IV. Provider business mailing address

831 NW COUNCIL DR SUITE 300
GRESHAM OR
97030-3721
US

V. Phone/Fax

Practice location:
  • Phone: 503-408-4078
  • Fax: 503-408-4077
Mailing address:
  • Phone: 503-408-4078
  • Fax: 503-408-4077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200150111NP
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: