Healthcare Provider Details

I. General information

NPI: 1629985593
Provider Name (Legal Business Name): IVON MORENO LOTHE RN
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

6180 NE 41ST AVE
PORTLAND OR
97211-7938
US

V. Phone/Fax

Practice location:
  • Phone: 503-257-1732
  • Fax:
Mailing address:
  • Phone: 503-734-0069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number099000432RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: