Provider Demographics
NPI:1962807917
Name:PORTELANCE, ELIZABETH MARIE (RD, RN, AG-ACNP-BC)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:PORTELANCE
Suffix:
Gender:F
Credentials:RD, RN, AG-ACNP-BC
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MARIE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3303 SW BOND AVE.
Mailing Address - Street 2:CH8N
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-494-4314
Mailing Address - Fax:503-346-6810
Practice Address - Street 1:3303 SW BOND AVE
Practice Address - Street 2:CH8N
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-494-4314
Practice Address - Fax:503-346-6810
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60551124363L00000X, 363LA2100X
TN19334363LA2100X
OR201501606NP-PP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1962807917Medicaid