MEDICARE: MRS. LAURIE LEIGH CALLAHAN MSN, FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	200650147NP	OR
2	163WR0006X	Registered Nurse First Assistant	095006655	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194821751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURIE LEIGH CALLAHAN MSN, FNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 3158
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97208-3158
Country	:	US
Telephone Number	:	541-734-7460
Fax Number	:	541-732-7461

Provider Business Practice Location Address
First Line	:	940 ROYAL AVE UNIT 350
Second Line	:
City	:	MEDFORD
State	:	OR
Zip	:	97504-6194
Country	:	US
Telephone Number	:	541-732-7460
Fax Number	:	541-734-7461

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	10/13/2020

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