Healthcare Provider Details

I. General information

NPI: 1417409764
Provider Name (Legal Business Name): FAYE BEDASO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13041 SE ALDER ST
PORTLAND OR
97233-1628
US

IV. Provider business mailing address

13041 SE ALDER ST
PORTLAND OR
97233-1628
US

V. Phone/Fax

Practice location:
  • Phone: 503-703-4539
  • Fax: 503-200-1068
Mailing address:
  • Phone: 503-703-4539
  • Fax: 503-200-1068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200940853RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: