=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639820137
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALICIA RENEE RUIZ APRN, FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2022
-----------------------------------------------------
Last Update Date | 10/15/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17437 BOONES FERRY RD STE 100
-----------------------------------------------------
City | LAKE OSWEGO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97035-6202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-387-3796
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11120 NE 33RD PL STE 202
-----------------------------------------------------
City | BELLEVUE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98004-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-823-1004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 202200176NP-PP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------