Provider Demographics
NPI:1891840310
Name:MEJIA, ELENA C (FNP, LAC)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:C
Last Name:MEJIA
Suffix:
Gender:F
Credentials:FNP, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 SE STEPHENS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5055
Mailing Address - Country:US
Mailing Address - Phone:503-740-1686
Mailing Address - Fax:
Practice Address - Street 1:30 W MAIN ST STE 202
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2872
Practice Address - Country:US
Practice Address - Phone:509-526-6944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR156530171100000X
WAAC60404698171100000X
WAAP60403410363LF0000X
OR093006358N1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR107959Medicare ID - Type Unspecified
ORP16211Medicare UPIN