Healthcare Provider Details

I. General information

NPI: 1326430554
Provider Name (Legal Business Name): SUPRADTANA NILE PIGROMSUK-VALENTE RRT, LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 RIVERBEND DR SACRED HEART MEDICAL CENTER
SPRINGFIELD OR
97477-8800
US

IV. Provider business mailing address

710 TYLER ST APT 7
EUGENE OR
97402-4656
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-2400
  • Fax:
Mailing address:
  • Phone: 541-653-3389
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License NumberRTP10137640
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number201394057LPN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: