Basic Information
Provider Information | |||||||||
NPI: | 1063507762 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | O'BRIEN | ||||||||
FirstName: | JOANNE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CFNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986838004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607291253 | ||||||||
FaxNumber: | 3607293185 | ||||||||
Practice Location | |||||||||
Address1: | 180 MELTON RD | ||||||||
Address2: |   | ||||||||
City: | CRESWELL | ||||||||
State: | OR | ||||||||
PostalCode: | 97426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412227700 | ||||||||
FaxNumber: | 5418955426 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2006 | ||||||||
LastUpdateDate: | 01/02/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 201602228NP-PP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 48178 | WV | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | COA.07283.NP | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | P01346092 | 01 | OH | RAILROAD MEDICARE - MHCPI | OTHER | 000000699826 | 01 | OH | ANTHEM | OTHER | 2398641 | 05 | OH |   | MEDICAID | 3810011350 | 05 | WV |   | MEDICAID | 000000680676 | 01 | OH | ANTHEM | OTHER |