Healthcare Provider Details

I. General information

NPI: 1740616770
Provider Name (Legal Business Name): LAURA BETHANY POWELL AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA BETHANY RICHTER AGACNP

II. Dates (important events)

Enumeration Date: 09/23/2013
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD MAIL CODE SJH-2
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

3181 SW SAM JACKSON PARK RD MAIL CODE SJH-2
PORTLAND OR
97239-3011
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-4910
  • Fax: 503-494-8368
Mailing address:
  • Phone: 503-494-4910
  • Fax: 503-494-8368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number201406086NP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number232481
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number5006497
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: