Healthcare Provider Details

I. General information

NPI: 1194821751
Provider Name (Legal Business Name): LAURIE LEIGH CALLAHAN MSN, FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 10/13/2020
Certification Date: 10/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 ROYAL AVE UNIT 350
MEDFORD OR
97504-6194
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 541-732-7460
  • Fax: 541-734-7461
Mailing address:
  • Phone: 541-734-7460
  • Fax: 541-732-7461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200650147NP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number095006655
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: