Healthcare Provider Details

I. General information

NPI: 1518678606
Provider Name (Legal Business Name): PENELOPE ROXAS LEAIR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10860 SE OAK ST
MILWAUKIE OR
97222-6694
US

IV. Provider business mailing address

4314 SW VESTA ST
PORTLAND OR
97219-7453
US

V. Phone/Fax

Practice location:
  • Phone: 503-652-8058
  • Fax:
Mailing address:
  • Phone: 847-840-9707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201142524RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: