Healthcare Provider Details

I. General information

NPI: 1154686020
Provider Name (Legal Business Name): BRONWEN KAYE ERICKSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BRONWEN KAYE WEICHERT

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2921 DOCTORS PARK DR
MEDFORD OR
97504-8127
US

IV. Provider business mailing address

675 N 5TH ST
JACKSONVILLE OR
97530-9659
US

V. Phone/Fax

Practice location:
  • Phone: 541-973-2551
  • Fax: 541-973-2835
Mailing address:
  • Phone: 541-214-2598
  • Fax: 458-202-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201350053NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: