Healthcare Provider Details

I. General information

NPI: 1134400195
Provider Name (Legal Business Name): GRETCHEN JOHANNA HAMPSHIRE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: GRETCHEN JOHANNA VANDERMEULEN RN

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 NE IRVING ST SUITE 250
PORTLAND OR
97232-2243
US

IV. Provider business mailing address

12360 SW HORIZON BLVD #102
BEAVERTON OR
97007-9349
US

V. Phone/Fax

Practice location:
  • Phone: 503-258-4200
  • Fax:
Mailing address:
  • Phone: 323-620-1697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200642204RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: