Healthcare Provider Details

I. General information

NPI: 1982041703
Provider Name (Legal Business Name): KIRSTEN GWYNN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24850 SE STARK ST STE 200
GRESHAM OR
97030-8320
US

IV. Provider business mailing address

PO BOX 3777
PORTLAND OR
97208-3777
US

V. Phone/Fax

Practice location:
  • Phone: 503-491-9444
  • Fax: 503-661-3430
Mailing address:
  • Phone: 503-413-3900
  • Fax: 503-413-3710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberMW010305
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number201405814NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: