Healthcare Provider Details

I. General information

NPI: 1942422068
Provider Name (Legal Business Name): BEVERLY A. FRISTAD RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 NE FORD ST
MCMINNVILLE OR
97128-4608
US

IV. Provider business mailing address

599 GARLAND CT N
KEIZER OR
97303-5640
US

V. Phone/Fax

Practice location:
  • Phone: 503-434-7525
  • Fax: 503-434-7549
Mailing address:
  • Phone: 503-779-5504
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number076035964RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: