Healthcare Provider Details

I. General information

NPI: 1619563491
Provider Name (Legal Business Name): AMY K BRAUN CPHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY K HAGEN

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 SE INTERNATIONAL WAY
MILWAUKIE OR
97222-4628
US

IV. Provider business mailing address

4560 SE INTERNATIONAL WAY
MILWAUKIE OR
97222-4628
US

V. Phone/Fax

Practice location:
  • Phone: 971-206-5197
  • Fax:
Mailing address:
  • Phone: 971-206-5197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberCPT-0010290
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: