Healthcare Provider Details

I. General information

NPI: 1053703504
Provider Name (Legal Business Name): CYNTHIA MEDRANO PMHNP, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 10/25/2024
Certification Date: 10/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 NE HALSEY ST BLDG 1, STE 200
PORTLAND OR
97213
US

IV. Provider business mailing address

4400 NE HALSEY ST BLDG 1, STE 200
PORTLAND OR
97213
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-6556
  • Fax:
Mailing address:
  • Phone: 503-215-6556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number61328
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number61328
License Number StateID
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201802878NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: