Healthcare Provider Details

I. General information

NPI: 1508225392
Provider Name (Legal Business Name): ELLEN PORTRAIT RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7150 SW DARTMOUTH ST
TIGARD OR
97223-7614
US

IV. Provider business mailing address

7150 SW DARTMOUTH ST
TIGARD OR
97223-7614
US

V. Phone/Fax

Practice location:
  • Phone: 503-968-3480
  • Fax: 503-227-0676
Mailing address:
  • Phone: 503-968-3480
  • Fax: 503-227-0676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number082011881RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: