Healthcare Provider Details

I. General information

NPI: 1659405298
Provider Name (Legal Business Name): LUCINDA CONNERY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5139 N LOMBARD ST
PORTLAND OR
97203-4403
US

IV. Provider business mailing address

100 CRESCENT DR
KELSO WA
98626-5307
US

V. Phone/Fax

Practice location:
  • Phone: 503-285-9871
  • Fax:
Mailing address:
  • Phone: 360-577-0668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number097006714RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200650184NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: