Healthcare Provider Details

I. General information

NPI: 1699608638
Provider Name (Legal Business Name): HAILEY PETTIJOHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1753 SW LAVA AVE
REDMOND OR
97756-2942
US

IV. Provider business mailing address

1753 SW LAVA AVE
REDMOND OR
97756-2942
US

V. Phone/Fax

Practice location:
  • Phone: 541-862-9068
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number10011205
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: