Healthcare Provider Details

I. General information

NPI: 1962807917
Provider Name (Legal Business Name): ELIZABETH MARIE PORTELANCE RD, RN, AG-ACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ELIZABETH MARIE SULLIVAN

II. Dates (important events)

Enumeration Date: 11/01/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 SW BOND AVE CH8N
PORTLAND OR
97239
US

IV. Provider business mailing address

3303 SW BOND AVE. CH8N
PORTLAND OR
97239
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-4314
  • Fax: 503-346-6810
Mailing address:
  • Phone: 503-494-4314
  • Fax: 503-346-6810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP60551124
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number19334
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP60551124
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number201501606NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: