Healthcare Provider Details

I. General information

NPI: 1902566193
Provider Name (Legal Business Name): KRYSTAL F LEBLANC CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2021
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1427 NW FLANDERS ST STE A
PORTLAND OR
97209-2646
US

IV. Provider business mailing address

2459 SE TUALATIN VALLEY HWY # 416
HILLSBORO OR
97123-7919
US

V. Phone/Fax

Practice location:
  • Phone: 503-972-0235
  • Fax:
Mailing address:
  • Phone: 503-972-0235
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number105948
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: