Healthcare Provider Details

I. General information

NPI: 1235546607
Provider Name (Legal Business Name): KATIE CONKLIN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NE KNOTT ST
PORTLAND OR
97212-3014
US

IV. Provider business mailing address

301 NE KNOTT ST
PORTLAND OR
97212-3014
US

V. Phone/Fax

Practice location:
  • Phone: 503-253-3910
  • Fax: 503-253-4297
Mailing address:
  • Phone: 503-253-3910
  • Fax: 503-253-4297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number105604
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201810182NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: