Healthcare Provider Details

I. General information

NPI: 1275939043
Provider Name (Legal Business Name): LEASEL WAYNE EVANS RN, MSN, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2014
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21900 WILLAMETTE DR STE 202
WEST LINN OR
97068-3284
US

IV. Provider business mailing address

21900 WILLAMETTE DR STE 202
WEST LINN OR
97068-3284
US

V. Phone/Fax

Practice location:
  • Phone: 503-653-0631
  • Fax: 503-653-1464
Mailing address:
  • Phone: 503-653-0631
  • Fax: 503-653-1464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number201709151NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number201406240RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: