=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851394464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BONNIE K KITTLESON FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2005
-----------------------------------------------------
Last Update Date | 03/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10000 SE MAIN ST STE 350
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97216-2474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-262-9800
-----------------------------------------------------
Fax | 971-262-9899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10000 SE MAIN ST STE 350
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97216-2474
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-262-9800
-----------------------------------------------------
Fax | 971-262-9899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 200450048NP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 53108
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 200450048NP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------