Healthcare Provider Details

I. General information

NPI: 1285822825
Provider Name (Legal Business Name): LANIDA MINNIEWEATHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 NE 165TH AVE
PORTLAND OR
97230-6148
US

IV. Provider business mailing address

985 SE 193RD AVE
PORTLAND OR
97233-5783
US

V. Phone/Fax

Practice location:
  • Phone: 503-408-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: