Healthcare Provider Details

I. General information

NPI: 1659923779
Provider Name (Legal Business Name): KATHERINE LATTIMER PMHNP-BC
Entity Type: Individual
Gender:
Sole Proprietor: N

Provider Other Name: KATHERINE LATTIMER-RYNEAL RN

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 NE BROADWAY
PORTLAND OR
97213-1422
US

IV. Provider business mailing address

2216 NE 21ST AVE
PORTLAND OR
97212-4622
US

V. Phone/Fax

Practice location:
  • Phone: 503-249-8787
  • Fax:
Mailing address:
  • Phone: 503-701-4880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201403853RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number201403853RN
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number201403853RN
License Number StateOR
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number10005847
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: