Provider Demographics
NPI:1326853367
Name:JAMES, DERONIA LYNN
Entity type:Individual
Prefix:
First Name:DERONIA
Middle Name:LYNN
Last Name:JAMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19849 NE HALSEY ST APT 122
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-7490
Mailing Address - Country:US
Mailing Address - Phone:503-666-6198
Mailing Address - Fax:
Practice Address - Street 1:1550 NW EASTMAN PKWY STE 175
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3859
Practice Address - Country:US
Practice Address - Phone:503-610-3853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-07
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR113245172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker