MEDICARE: DIANA ELIZABETH GWINN DD1

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	311ZA0620X	Adult Care Home Facility	10465	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	:	1386122687
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA ELIZABETH GWINN DD1

Provider Business Mailing Address
First Line	:	16405 NE FARGO CIR
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97230-5513
Country	:	US
Telephone Number	:	503-484-7287
Fax Number	:	503-210-5974

Provider Business Practice Location Address
First Line	:	16405 NE FARGO CIR
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97230-5513
Country	:	US
Telephone Number	:	503-484-7287
Fax Number	:	503-210-5974

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

Provider Enumeration Date	:	07/30/2018
Last Update Date	:	07/30/2018

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