Healthcare Provider Details

I. General information

NPI: 1679255004
Provider Name (Legal Business Name): KARLY GLENN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2023
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16463 BOONES FERRY RD STE 300
LAKE OSWEGO OR
97035-4376
US

IV. Provider business mailing address

16463 BOONES FERRY RD STE 300
LAKE OSWEGO OR
97035-4376
US

V. Phone/Fax

Practice location:
  • Phone: 503-658-9351
  • Fax:
Mailing address:
  • Phone: 503-658-9351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA222423
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: