Provider Demographics
NPI:1063507762
Name:O'BRIEN, JOANNE M (CFNP)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:M
Last Name:O'BRIEN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1253
Mailing Address - Fax:360-729-3185
Practice Address - Street 1:180 MELTON RD
Practice Address - Street 2:
Practice Address - City:CRESWELL
Practice Address - State:OR
Practice Address - Zip Code:97426
Practice Address - Country:US
Practice Address - Phone:541-222-7700
Practice Address - Fax:541-895-5426
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201602228NP-PP363LF0000X
WV48178363LF0000X
OHCOA.07283.NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP01346092OtherRAILROAD MEDICARE - MHCPI
OH000000699826OtherANTHEM
OH2398641Medicaid
WV3810011350Medicaid
OH000000680676OtherANTHEM
OH86781Medicare PIN
OH2398641Medicaid
WV3810011350Medicaid