Healthcare Provider Details

I. General information

NPI: 1447823810
Provider Name (Legal Business Name): TINA MARIE CONKLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3099 NE DIAMOND LAKE BLVD
ROSEBURG OR
97470-3655
US

IV. Provider business mailing address

PO BOX 1121
ROSEBURG OR
97470-0254
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-3469
  • Fax:
Mailing address:
  • Phone: 541-672-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number200330020LPN
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number21-QMHA-R-1339
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: