Healthcare Provider Details

I. General information

NPI: 1639221609
Provider Name (Legal Business Name): ELIZABETH COLBERT MOLINE N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 11/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 SE STRATUS AVE WILLAMETTE VALLEY MEDICAL CENTER, OCCUPATIONAL MEDICINE
MCMINNVILLE OR
97128-8872
US

IV. Provider business mailing address

1211 NW THOMSEN LN
MCMINNVILLE OR
97128-2831
US

V. Phone/Fax

Practice location:
  • Phone: 503-435-6556
  • Fax:
Mailing address:
  • Phone: 503-472-1016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number375372
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71000684A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200950008NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: