Provider Demographics
NPI:1023568649
Name:NIEDERMEYER, SALLY JO (RN)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:JO
Last Name:NIEDERMEYER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 404
Mailing Address - Street 2:
Mailing Address - City:GOVERNMENT CAMP
Mailing Address - State:OR
Mailing Address - Zip Code:97028-0404
Mailing Address - Country:US
Mailing Address - Phone:503-505-4627
Mailing Address - Fax:
Practice Address - Street 1:5211 NE GLISAN ST BLDG C
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3052
Practice Address - Country:US
Practice Address - Phone:503-215-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR080045857RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health