=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255820239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FITZGERALD FAMILY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/06/2018
-----------------------------------------------------
Last Update Date | 05/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 289 E ELLENDALE AVE STE 602
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97338-1570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-612-1588
-----------------------------------------------------
Fax | 503-831-3215
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 170 W ELLENDALE AVE STE 103
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97338-1456
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-612-1588
-----------------------------------------------------
Fax | 503-831-3215
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | MRS. ERIN SANFORD FITZGERALD
-----------------------------------------------------
Credential | FNP-BC
-----------------------------------------------------
Telephone | 971-612-1588
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 2015011081
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------