Provider Demographics
NPI:1457012791
Name:BALANETSKAYA, DARYA (ACPCNP)
Entity type:Individual
Prefix:
First Name:DARYA
Middle Name:
Last Name:BALANETSKAYA
Suffix:
Gender:F
Credentials:ACPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17727 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-4803
Mailing Address - Country:US
Mailing Address - Phone:503-215-9800
Mailing Address - Fax:
Practice Address - Street 1:17727 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-4803
Practice Address - Country:US
Practice Address - Phone:503-215-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-08
Last Update Date:2024-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202206690NP-PP363LP2300X, 363L00000X, 363LG0600X
OR201504283RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse