Healthcare Provider Details

I. General information

NPI: 1114165503
Provider Name (Legal Business Name): PAULA JEAN PRINCE AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2009
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9135 SW BARNES RD STE 461
PORTLAND OR
97225-6643
US

IV. Provider business mailing address

PO BOX 3158
PORTLAND OR
97208-3158
US

V. Phone/Fax

Practice location:
  • Phone: 503-216-1150
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number097006495RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number201605367NP-PP
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number201605367NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: