Healthcare Provider Details

I. General information

NPI: 1730523788
Provider Name (Legal Business Name): KRISTEN ELAINE DERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 10/03/2022
Certification Date: 10/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12116 SE MILL PLAIN BLVD STE 1
VANCOUVER WA
98684-6000
US

IV. Provider business mailing address

5105 SW ELM AVE
BEAVERTON OR
97005-4230
US

V. Phone/Fax

Practice location:
  • Phone: 360-719-1512
  • Fax: 503-254-0576
Mailing address:
  • Phone: 541-659-9318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3579ATI
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number60503088
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: