Healthcare Provider Details

I. General information

NPI: 1619709441
Provider Name (Legal Business Name): JOY AUDREY GUMMOW FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 W MAIN ST
MOLALLA OR
97038-9352
US

IV. Provider business mailing address

PO BOX 3417
PORTLAND OR
97208-3417
US

V. Phone/Fax

Practice location:
  • Phone: 503-874-5653
  • Fax:
Mailing address:
  • Phone: 503-413-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10030186
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10030186
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: