Healthcare Provider Details

I. General information

NPI: 1891560785
Provider Name (Legal Business Name): MICHELLE LANE ROCA BALTZOR NBC-HWC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41118 TAYLOR LN
PENDLETON OR
97801-9825
US

IV. Provider business mailing address

41118 TAYLOR LN
PENDLETON OR
97801-9825
US

V. Phone/Fax

Practice location:
  • Phone: 541-561-4163
  • Fax:
Mailing address:
  • Phone: 541-561-4163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberA-3668707
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: