Provider Demographics
NPI:1386384543
Name:GERKEN, CHANDRA ELISE (FSS)
Entity type:Individual
Prefix:
First Name:CHANDRA
Middle Name:ELISE
Last Name:GERKEN
Suffix:
Gender:F
Credentials:FSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 SE 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-1453
Mailing Address - Country:US
Mailing Address - Phone:503-358-5027
Mailing Address - Fax:
Practice Address - Street 1:209 SW 4TH AVE STE 520
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-1825
Practice Address - Country:US
Practice Address - Phone:503-988-5464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-29
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13863845543175T00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist