Healthcare Provider Details

I. General information

NPI: 1750246872
Provider Name (Legal Business Name): KERRY ELLEN GRETHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/20/2025
Last Update Date: 12/20/2025
Certification Date: 12/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3928 NE 13TH AVE
PORTLAND OR
97212-1305
US

IV. Provider business mailing address

3928 NE 13TH AVE
PORTLAND OR
97212-1305
US

V. Phone/Fax

Practice location:
  • Phone: 503-956-2579
  • Fax:
Mailing address:
  • Phone: 503-956-2579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License Number10265111
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: