Healthcare Provider Details

I. General information

NPI: 1164491148
Provider Name (Legal Business Name): DONNA L JOHANNES ANP, GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 10/31/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17727 E BURNSIDE ST
PORTLAND OR
97233
US

IV. Provider business mailing address

17727 E BURNSIDE ST
PORTLAND OR
97233
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-9800
  • Fax:
Mailing address:
  • Phone: 503-215-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number000037597N3
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number000037597N3
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: