Basic Information
| Provider Information | |||||||||
| NPI: | 1386636736 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEATHERWOOD | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | EIKO BERNEL | ||||||||
| NamePrefix: | |||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3303 SW BOND AVE. CH10U | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033461500 | ||||||||
| FaxNumber: | 5033461501 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 SW BOND AVE. | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033461500 | ||||||||
| FaxNumber: | 5033461501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2005 | ||||||||
| LastUpdateDate: | 06/12/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 200350011NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 200340159RN | OR | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 9641440 | 05 | WA | MEDICAID | 022498 | 05 | OR | MEDICAID |