Provider Demographics
NPI:1972263184
Name:LA MORTICELLA, KIMBERLEY (WHNP-BC)
Entity type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:
Last Name:LA MORTICELLA
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6027 SE PARDEE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-4756
Mailing Address - Country:US
Mailing Address - Phone:503-887-6482
Mailing Address - Fax:
Practice Address - Street 1:6027 SE PARDEE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-4756
Practice Address - Country:US
Practice Address - Phone:503-887-6482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202109521NP-PP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health