Healthcare Provider Details

I. General information

NPI: 1063560217
Provider Name (Legal Business Name): KATHLEEN GREGORY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2007
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 NW 6TH ST SUITE A
MCMINNVILLE OR
97128-5582
US

IV. Provider business mailing address

3727 NE MARTIN LUTHER KING JR BLVD ATTN: CREDENTIALING
PORTLAND OR
97212-1112
US

V. Phone/Fax

Practice location:
  • Phone: 503-775-4931
  • Fax: 503-788-7285
Mailing address:
  • Phone: 503-775-4931
  • Fax: 503-788-7285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number080044677NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: