Healthcare Provider Details

I. General information

NPI: 1114910122
Provider Name (Legal Business Name): SANDRA J YOUNGWORTH ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 SW BOND AVE STE 7
PORTLAND OR
97239-4501
US

IV. Provider business mailing address

3303 SW BOND AVE STE 7
PORTLAND OR
97239-4501
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-6594
  • Fax: 503-494-5385
Mailing address:
  • Phone: 503-494-6594
  • Fax: 503-494-5385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP30007006
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberH156296
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number200550058NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: