=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871711143
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBECCA ANN PODHORA PMHNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 09/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 190 NW 4TH ST
-----------------------------------------------------
City | PRINEVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97754-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-233-7735
-----------------------------------------------------
Fax | 541-566-7633
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8081 NW SAGEBRUSH LN
-----------------------------------------------------
City | PRINEVILLE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97754-8306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-233-7735
-----------------------------------------------------
Fax | 541-566-7633
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 20075001
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 200750010NP PMHNP-PP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------