Basic Information
Provider Information | |||||||||
NPI: | 1144999210 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BENNETT | ||||||||
FirstName: | ROSEMARY | ||||||||
MiddleName: | HEATHER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | POHLENZ | ||||||||
OtherFirstName: | ROSEMARY | ||||||||
OtherMiddleName: | HEATHER | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 530 NW 27TH ST | ||||||||
Address2: |   | ||||||||
City: | CORVALLIS | ||||||||
State: | OR | ||||||||
PostalCode: | 973305223 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5417666835 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 414 N 2ND ST | ||||||||
Address2: |   | ||||||||
City: | JEFFERSON | ||||||||
State: | OR | ||||||||
PostalCode: | 973529706 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5033744343 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/10/2021 | ||||||||
LastUpdateDate: | 09/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 200842417RN | OR | Y |   | Nursing Service Providers | Registered Nurse |   |
ID Information
ID | Type | State | Issuer | Description | 200842417RN | 01 | OR | OSBN | OTHER |