Basic Information
| Provider Information | |||||||||
| NPI: | 1861507279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KLESH | ||||||||
| FirstName: | MARYLYN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4855 SW WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970053460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032493434 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4855 SW WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | BEAVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970053460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036437565 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
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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 | 163WP0808X | 000024615N6 | OR | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health |
No ID Information.