Healthcare Provider Details

I. General information

NPI: 1457564817
Provider Name (Legal Business Name): ORAWAN LAOCHUMNANVANIT PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 03/19/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 NE HANCOCK ST SUITE 301
PORTLAND OR
97212-5321
US

IV. Provider business mailing address

3939 NE HANCOCK STREET SUITE 301
PORTLAND OR
97212-2933
US

V. Phone/Fax

Practice location:
  • Phone: 503-545-6465
  • Fax: 503-287-4940
Mailing address:
  • Phone: 503-545-6465
  • Fax: 503-287-4940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP30007896
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number20075004NP PMHNP PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: