Healthcare Provider Details

I. General information

NPI: 1588981690
Provider Name (Legal Business Name): MISS DIANE E WELLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 04/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 NE 162ND AVE
PORTLAND OR
97230-5760
US

IV. Provider business mailing address

570 NW BIRDSDALE AVE
GRESHAM OR
97030-6643
US

V. Phone/Fax

Practice location:
  • Phone: 503-408-4741
  • Fax:
Mailing address:
  • Phone: 503-665-2197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: