Healthcare Provider Details

I. General information

NPI: 1669786174
Provider Name (Legal Business Name): EMILY A LIEUALLEN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 07/19/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STRAWBERRY WILDERNESS CLINIC 180 FORD RD.
JOHN DAY OR
97845
US

IV. Provider business mailing address

180 FORD RD
JOHN DAY OR
97845-2009
US

V. Phone/Fax

Practice location:
  • Phone: 541-575-0404
  • Fax: 541-575-4158
Mailing address:
  • Phone: 475-750-4045
  • Fax: 475-754-1585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO164168
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: