Provider Demographics
NPI:1043395619
Name:HORTON, MARY KRISTINE (ANP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KRISTINE
Last Name:HORTON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12381 SE CREST WAY
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97236-6177
Mailing Address - Country:US
Mailing Address - Phone:503-421-2367
Mailing Address - Fax:503-279-8926
Practice Address - Street 1:2701 NW VAUGHN ST
Practice Address - Street 2:#305
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5311
Practice Address - Country:US
Practice Address - Phone:503-279-8252
Practice Address - Fax:503-279-8926
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000026282N3 ANP-PP363LA2200X
OR163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR270439Medicaid