MEDICARE: AMY BURKE GWARTNEY LMT #20514

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	172V00000X	Community Health Worker	20514	OR

General Provider Information

NPI Number	:	1780066514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY BURKE GWARTNEY LMT #20514

Provider Business Mailing Address
First Line	:	1842 NW 25TH AVE
Second Line	:	#1
City	:	PORTLAND
State	:	OR
Zip	:	97210
Country	:	US
Telephone Number	:	503-593-1399
Fax Number	:

Provider Business Practice Location Address
First Line	:	1842 NW 25TH AVE
Second Line	:	#1
City	:	PORTLAND
State	:	OR
Zip	:	97210
Country	:	US
Telephone Number	:	503-593-1399
Fax Number	:

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

Provider Enumeration Date	:	06/29/2015
Last Update Date	:	06/29/2015

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