Healthcare Provider Details

I. General information

NPI: 1801353297
Provider Name (Legal Business Name): GWENDOLYN KERSEY PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2019
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 CENTER ST NE OREGON STATE HOSPITAL
SALEM OR
97301
US

IV. Provider business mailing address

908 SW GAINES ST APT 11
PORTLAND OR
97239-2959
US

V. Phone/Fax

Practice location:
  • Phone: 503-945-2800
  • Fax:
Mailing address:
  • Phone: 509-991-4377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number201708298RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201906508NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: