Healthcare Provider Details

I. General information

NPI: 1306399027
Provider Name (Legal Business Name): CHARLES CHRISTIAN KOHNKEN APRN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 SE WASHINGTON ST
HILLSBORO OR
97123-4142
US

IV. Provider business mailing address

833 CALLISTA CAY LOOP
TARPON SPRINGS FL
34689-0002
US

V. Phone/Fax

Practice location:
  • Phone: 503-755-6703
  • Fax: 503-755-6704
Mailing address:
  • Phone: 727-810-1556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN 9331526
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN9331526
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP11291
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10035421
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: