MEDICARE: ILLUMINA INTEGRATIVE PSYCHIATRY

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	103TC1900X	Counseling Psychologist
2	171400000X	Health & Wellness Coach
3	363L00000X	Nurse Practitioner
4	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1932067139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ILLUMINA INTEGRATIVE PSYCHIATRY

Provider Business Mailing Address
First Line	:	1109 NE PRESCOTT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-4659
Country	:	US
Telephone Number	:	208-696-8107
Fax Number	:

Provider Business Practice Location Address
First Line	:	1109 NE PRESCOTT ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-4659
Country	:	US
Telephone Number	:	208-696-8107
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTA ELIZABETH MILLER
Credential	:	APRN, PMHNP-BC
Telephone Number	:	208-596-8107

Provider Enumeration Date	:	01/14/2026
Last Update Date	:	01/14/2026

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