Provider Demographics
NPI:1285740985
Name:ANDERSON, DARLENE J (NP)
Entity type:Individual
Prefix:
First Name:DARLENE
Middle Name:J
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:30748 SE DIVISION DR
Mailing Address - Street 2:
Mailing Address - City:TROUTDALE
Mailing Address - State:OR
Mailing Address - Zip Code:97060-9494
Mailing Address - Country:US
Mailing Address - Phone:503-663-7089
Mailing Address - Fax:503-663-7089
Practice Address - Street 1:4610 SE BELMONT ST
Practice Address - Street 2:SUITE 60
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-1752
Practice Address - Country:US
Practice Address - Phone:503-988-5303
Practice Address - Fax:503-988-5112
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR084063342N4363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR291811Medicaid
OR291811Medicaid