Healthcare Provider Details

I. General information

NPI: 1093068710
Provider Name (Legal Business Name): SUELLEN YOUNG R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 NE GLISAN ST
PORTLAND OR
97213-2333
US

IV. Provider business mailing address

4531 SE BELMONT ST STE 100
PORTLAND OR
97215-1675
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-3738
  • Fax: 503-215-6942
Mailing address:
  • Phone: 503-215-3738
  • Fax: 503-215-6942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number078041686RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: