Healthcare Provider Details

I. General information

NPI: 1801767165
Provider Name (Legal Business Name): MEGAN KNICKERBOCKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 NE ALOCLEK DR
HILLSBORO OR
97124-7521
US

IV. Provider business mailing address

5825 NE RAY CIR
HILLSBORO OR
97124-6436
US

V. Phone/Fax

Practice location:
  • Phone: 503-716-7896
  • Fax:
Mailing address:
  • Phone: 503-716-7896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number200342053RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: