Healthcare Provider Details

I. General information

NPI: 1053216036
Provider Name (Legal Business Name): MADELINE MCDONNELL RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 NE GLISAN ST
PORTLAND OR
97213-2933
US

IV. Provider business mailing address

11508 SE 48TH AVE
MILWAUKIE OR
97222-5414
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-1111
  • Fax:
Mailing address:
  • Phone: 773-984-6797
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10032513
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: