Healthcare Provider Details

I. General information

NPI: 1922485135
Provider Name (Legal Business Name): MARY CAITLIN WELLS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2015
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12710 SE DIVISION ST
PORTLAND OR
97236-3134
US

IV. Provider business mailing address

12710 SE DIVISION ST
PORTLAND OR
97236-3134
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-5155
  • Fax: 503-988-5185
Mailing address:
  • Phone: 503-988-5155
  • Fax: 503-988-5185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201502244NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: