Healthcare Provider Details

I. General information

NPI: 1801449301
Provider Name (Legal Business Name): EVA CICILIAN ADVANCE PRACTICE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 NE 106TH AVE
PORTLAND OR
97220-3934
US

IV. Provider business mailing address

PO BOX 8459
PORTLAND OR
97207-8459
US

V. Phone/Fax

Practice location:
  • Phone: 503-460-0405
  • Fax:
Mailing address:
  • Phone: 503-238-0769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number201142770RN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number202006868NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: