Provider Demographics
NPI:1194351288
Name:GUTBROD, DARLENE MICHELLE (CMA)
Entity type:Individual
Prefix:
First Name:DARLENE
Middle Name:MICHELLE
Last Name:GUTBROD
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 NE EVANS ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-3923
Mailing Address - Country:US
Mailing Address - Phone:503-434-7523
Mailing Address - Fax:503-434-9846
Practice Address - Street 1:627 NE EVANS ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-3923
Practice Address - Country:US
Practice Address - Phone:503-434-7523
Practice Address - Fax:503-434-9846
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-20
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR975595376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR975595OtherMEDICAL ASSISTANT