Healthcare Provider Details

I. General information

NPI: 1205698784
Provider Name (Legal Business Name): MARIE AUGUSTINA ESCAMILLA NUTRITIONIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2230 NW PETTYGROVE ST STE 110
PORTLAND OR
97210-2659
US

IV. Provider business mailing address

5621 NE 30TH AVE
PORTLAND OR
97211-6807
US

V. Phone/Fax

Practice location:
  • Phone: 503-227-0350
  • Fax:
Mailing address:
  • Phone: 989-316-6748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: