Healthcare Provider Details

I. General information

NPI: 1336056100
Provider Name (Legal Business Name): LILY BARAKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11611 NE AINSWORTH CIR
PORTLAND OR
97220-9017
US

IV. Provider business mailing address

11740 SE MAIN ST
PORTLAND OR
97216-3958
US

V. Phone/Fax

Practice location:
  • Phone: 971-266-7582
  • Fax:
Mailing address:
  • Phone: 971-266-7582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number201340637RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: