Healthcare Provider Details

I. General information

NPI: 1558486209
Provider Name (Legal Business Name): CHALLIS ANNETTE CASEBOLT WHC NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 01/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1975 MCPHERSON #1
NORTH BEND OR
97459
US

IV. Provider business mailing address

PO BOX 393
NORTH BEND OR
97459
US

V. Phone/Fax

Practice location:
  • Phone: 541-756-2020
  • Fax: 541-756-5828
Mailing address:
  • Phone: 530-510-3976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number200050116NPWHCNPPP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: