Healthcare Provider Details

I. General information

NPI: 1669481396
Provider Name (Legal Business Name): LYNDA BURNETTE GROGAN PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

PO BOX 1034 P35C
PORTLAND OR
97207-1034
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax: 503-273-5243
Mailing address:
  • Phone: 503-220-8262
  • Fax: 503-273-5243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number900001476N6
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: