Healthcare Provider Details

I. General information

NPI: 1477194181
Provider Name (Legal Business Name): ELIZABETH BODENNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6011 NE OREGON ST
PORTLAND OR
97213-4300
US

IV. Provider business mailing address

9133 N ALLEGHENY AVE
PORTLAND OR
97203-2303
US

V. Phone/Fax

Practice location:
  • Phone: 971-319-4827
  • Fax: 503-662-6221
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: