Healthcare Provider Details

I. General information

NPI: 1487985305
Provider Name (Legal Business Name): PENNY L KOLLEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 NW GARDEN VALLEY BLVD STE 46B
ROSEBURG OR
97471-6528
US

IV. Provider business mailing address

363 HIGH ST
EUGENE OR
97401-2309
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-1599
  • Fax:
Mailing address:
  • Phone: 541-465-3966
  • Fax: 541-465-3967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number084060835RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: