Healthcare Provider Details

I. General information

NPI: 1720997406
Provider Name (Legal Business Name): PRISCILLA JOHANSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2026
Last Update Date: 09/07/2026
Certification Date: 09/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7124 S VIRGINIA AVE
PORTLAND OR
97219-3035
US

IV. Provider business mailing address

7124 S VIRGINIA AVE
PORTLAND OR
97219-3035
US

V. Phone/Fax

Practice location:
  • Phone: 503-548-8622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number13666757
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: