Healthcare Provider Details

I. General information

NPI: 1245396720
Provider Name (Legal Business Name): LUCINDA ANN BALLAS ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17704 JEAN WAY 105
LAKE OSWEGO OR
97035-5497
US

IV. Provider business mailing address

770 NE 31ST PL
CANBY OR
97013-2104
US

V. Phone/Fax

Practice location:
  • Phone: 503-675-6776
  • Fax: 503-675-2572
Mailing address:
  • Phone: 503-651-3322
  • Fax: 503-651-3325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number079034619N3 ANP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: