Provider Demographics
NPI:1396154944
Name:MARY ANN PENNY DOMM
Entity type:Organization
Organization Name:MARY ANN PENNY DOMM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:PENNY
Authorized Official - Last Name:DOMM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-477-7222
Mailing Address - Street 1:8550 SW APPLE WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-1772
Mailing Address - Country:US
Mailing Address - Phone:503-477-7222
Mailing Address - Fax:503-894-9699
Practice Address - Street 1:8550 SW APPLE WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-1772
Practice Address - Country:US
Practice Address - Phone:503-477-7222
Practice Address - Fax:503-894-9699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-07
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 2983261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service