Provider Demographics
NPI:1982422697
Name:IVERSON, SHYLA DESIRAE
Entity type:Individual
Prefix:
First Name:SHYLA
Middle Name:DESIRAE
Last Name:IVERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 NE TRISHA DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-4007
Mailing Address - Country:US
Mailing Address - Phone:503-396-0228
Mailing Address - Fax:
Practice Address - Street 1:3455 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3076
Practice Address - Country:US
Practice Address - Phone:503-396-0228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201141116RN163WL0100X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant