Provider Demographics
NPI:1386317303
Name:PHOENIX, CLARA
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:PHOENIX
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 1:2095 OPAQUE AVE NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-2138
Mailing Address - Country:US
Mailing Address - Phone:503-523-8203
Mailing Address - Fax:
Practice Address - Street 1:1750 SW SKYLINE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-2533
Practice Address - Country:US
Practice Address - Phone:503-444-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program