Basic Information
| Provider Information | |||||||||
| NPI: | 1194351288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUTBROD | ||||||||
| FirstName: | DARLENE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CMA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 627 NE EVANS ST | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971283923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034347523 | ||||||||
| FaxNumber: | 5034349846 | ||||||||
| Practice Location | |||||||||
| Address1: | 627 NE EVANS ST | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971283923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034347523 | ||||||||
| FaxNumber: | 5034349846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2020 | ||||||||
| LastUpdateDate: | 03/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 376K00000X | 975595 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Related Providers | Nurse's Aide |
ID Information
| ID | Type | State | Issuer | Description | 975595 | 01 | OR | MEDICAL ASSISTANT | OTHER |