Healthcare Provider Details

I. General information

NPI: 1356784144
Provider Name (Legal Business Name): ALYSSA JOANN COLBY IBCLC, CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 02/26/2021
Certification Date: 02/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 NW BEAVER ST STE 100
PRINEVILLE OR
97754-1802
US

IV. Provider business mailing address

591 NE 2ND ST
PRINEVILLE OR
97754-2014
US

V. Phone/Fax

Practice location:
  • Phone: 541-447-5165
  • Fax: 541-447-3093
Mailing address:
  • Phone: 541-280-3031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberDEM-LD-10154656
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: