Healthcare Provider Details

I. General information

NPI: 1366445967
Provider Name (Legal Business Name): JOANNA L LEZAK ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 NW 22ND AVE SUITE 110
PORTLAND OR
97210-2900
US

IV. Provider business mailing address

1130 NW 22ND AVE SUITE 110
PORTLAND OR
97210-2900
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-3940
  • Fax: 503-413-1860
Mailing address:
  • Phone: 503-413-3940
  • Fax: 503-413-1860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number200450078NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: