Healthcare Provider Details

I. General information

NPI: 1720255854
Provider Name (Legal Business Name): KAREN E NIBBLETT PMHNP, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13007 NE GLISAN ST
PORTLAND OR
97230-2545
US

IV. Provider business mailing address

13007 NE GLISAN ST
PORTLAND OR
97230-2545
US

V. Phone/Fax

Practice location:
  • Phone: 503-215-5600
  • Fax: 503-215-7864
Mailing address:
  • Phone: 503-215-5600
  • Fax: 503-215-7864

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200450084 NP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number200470021CNS
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: