Healthcare Provider Details

I. General information

NPI: 1619651684
Provider Name (Legal Business Name): OSA BRIANA PECK RN, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 06/12/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16770 SW EDY RD STE 102A
SHERWOOD OR
97140-9679
US

IV. Provider business mailing address

4400 NE HALSEY ST BLDG 2
PORTLAND OR
97213-1545
US

V. Phone/Fax

Practice location:
  • Phone: 855-360-5456
  • Fax:
Mailing address:
  • Phone: 855-360-5456
  • Fax: 503-215-6240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number200040786RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: