Healthcare Provider Details

I. General information

NPI: 1518139617
Provider Name (Legal Business Name): STACY M ANDERSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1475 MT. HOOD AVE
WOODBURN OR
97071
US

IV. Provider business mailing address

PO BOX 278
WOODBURN OR
97071
US

V. Phone/Fax

Practice location:
  • Phone: 971-983-5214
  • Fax: 971-983-5219
Mailing address:
  • Phone: 971-983-5260
  • Fax: 971-983-5326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number200850153NPPMHNP-PP
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number200850153NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: