Healthcare Provider Details

I. General information

NPI: 1043924830
Provider Name (Legal Business Name): CATHERINE ZAGIDULLINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2023
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18460 SW BOONES FERRY RD APT KK307
PORTLAND OR
97224-7063
US

IV. Provider business mailing address

18460 SW BOONES FERRY RD APT KK307
PORTLAND OR
97224-7063
US

V. Phone/Fax

Practice location:
  • Phone: 971-708-2254
  • Fax:
Mailing address:
  • Phone: 971-708-2254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number860268
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: