Healthcare Provider Details

I. General information

NPI: 1851950372
Provider Name (Legal Business Name): KATHLEEN POLITO NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2019
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3710 SW US VETERANS HOSPITAL RD
PORTLAND OR
97239-2964
US

V. Phone/Fax

Practice location:
  • Phone: 540-451-1032
  • Fax:
Mailing address:
  • Phone: 503-220-8262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number201501124RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number202111916NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: