Provider Demographics
NPI:1033853783
Name:NORTHWEST VITALITY GROUP
Entity Type:Organization
Organization Name:NORTHWEST VITALITY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER/CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:FAY
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-A
Authorized Official - Phone:503-757-8535
Mailing Address - Street 1:3 MONROW PKWY
Mailing Address - Street 2:STE P #714
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035
Mailing Address - Country:US
Mailing Address - Phone:503-477-5084
Mailing Address - Fax:
Practice Address - Street 1:9233 SW 52ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-5003
Practice Address - Country:US
Practice Address - Phone:503-757-8535
Practice Address - Fax:971-223-0949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center