Basic Information
| Provider Information | |||||||||
| NPI: | 1174993026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WESTON | ||||||||
| FirstName: | LATANYA | ||||||||
| MiddleName: | NIKKOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | LATANYA | ||||||||
| OtherMiddleName: | NIKKOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2051 KAEN RD | ||||||||
| Address2: | 367 | ||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970454035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036503110 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1425 BEAVERCREEK RD | ||||||||
| Address2: | |||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036558471 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2015 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 201609584NP-PP | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | RN 188640 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP2300X | 0024176026 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LP2300X | AP60726772 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LP2300X | RN188640 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.