Healthcare Provider Details

I. General information

NPI: 1811667462
Provider Name (Legal Business Name): ALISA MAIA ILLO ND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4246 SE BELMONT ST STE 5
PORTLAND OR
97215-1676
US

IV. Provider business mailing address

PO BOX 1125
LAKE OSWEGO OR
97035-0503
US

V. Phone/Fax

Practice location:
  • Phone: 503-445-8114
  • Fax:
Mailing address:
  • Phone: 503-593-1210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: