Provider Demographics
NPI:1386938033
Name:LAFOLETTE, TIMOTHY J (PMHNP)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:J
Last Name:LAFOLETTE
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:J
Other - Last Name:LAFOLETTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHNP
Mailing Address - Street 1:PO BOX 66722
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97290-6722
Mailing Address - Country:US
Mailing Address - Phone:503-389-5366
Mailing Address - Fax:866-635-1779
Practice Address - Street 1:6309 SE 86TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-5464
Practice Address - Country:US
Practice Address - Phone:503-389-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-29
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60302047163W00000X
OR201042898RN163W00000X
WAAP60302050363LP0808X
OR201250134NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500649528Medicaid
WA2022839Medicaid