Healthcare Provider Details

I. General information

NPI: 1841797990
Provider Name (Legal Business Name): ANGELA MARIE VITEK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 MOUNT HOOD AVE
WOODBURN OR
97071-9066
US

IV. Provider business mailing address

PO BOX 3417
PORTLAND OR
97208-3417
US

V. Phone/Fax

Practice location:
  • Phone: 971-983-5360
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number58246
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number202010842NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: