Healthcare Provider Details

I. General information

NPI: 1376460212
Provider Name (Legal Business Name): MANDA JANE HERSTAD LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 CHURCH ST NE
SALEM OR
97301-2404
US

IV. Provider business mailing address

8444 N 90TH ST STE 100
SCOTTSDALE AZ
85258-4437
US

V. Phone/Fax

Practice location:
  • Phone: 503-991-5903
  • Fax:
Mailing address:
  • Phone: 602-248-8886
  • Fax: 602-854-0504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number202009204LPN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: