Basic Information
| Provider Information | |||||||||
| NPI: | 1861857880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELKNAP | ||||||||
| FirstName: | BONNIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3587 HEATHROW WAY | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418588170 | ||||||||
| FaxNumber: | 5418588167 | ||||||||
| Practice Location | |||||||||
| Address1: | 847 NE 19TH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380769 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 175T00000X | OR | N | 372600000X | Y | Nursing Service Related Providers | Adult Companion |
ID Information
| ID | Type | State | Issuer | Description | 1861857880 | 05 | OR | MEDICAID |