Healthcare Provider Details

I. General information

NPI: 1780458976
Provider Name (Legal Business Name): KATELYN PROPHETER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2023
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 RIVERBEND DR
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

2699 W 15TH AVE
JUNCTION CITY OR
97448-8363
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-7300
  • Fax:
Mailing address:
  • Phone: 915-261-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number202112788RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: