Healthcare Provider Details

I. General information

NPI: 1083036990
Provider Name (Legal Business Name): LAURA DILLARD NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA IWATA RN

II. Dates (important events)

Enumeration Date: 01/11/2014
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10822 SE 82ND AVE
HAPPY VALLEY OR
97086
US

IV. Provider business mailing address

1027 E BURNSIDE ST
PORTLAND OR
97214-1328
US

V. Phone/Fax

Practice location:
  • Phone: 503-239-8400
  • Fax:
Mailing address:
  • Phone: 503-239-8400
  • Fax: 503-296-2022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201705362NP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201705362NP-PP
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201142492RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: