Healthcare Provider Details

I. General information

NPI: 1588862668
Provider Name (Legal Business Name): KELLY ANNE GOUDREAU CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 07/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSP RD
PORTLAND OR
97207-1034
US

IV. Provider business mailing address

4118 NE 131ST PL
PORTLAND OR
97230-1420
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax: 503-220-3441
Mailing address:
  • Phone: 503-220-8262
  • Fax: 503-220-3441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: