Healthcare Provider Details

I. General information

NPI: 1730796525
Provider Name (Legal Business Name): EDEN FAIR FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 NW 4TH ST APT A
REDMOND OR
97756-1328
US

IV. Provider business mailing address

1805 E 19TH ST
THE DALLES OR
97058-3365
US

V. Phone/Fax

Practice location:
  • Phone: 541-548-7761
  • Fax: 541-598-3485
Mailing address:
  • Phone: 541-296-2201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number202008004NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: