Provider Demographics
NPI:1104835297
Name:NAMETKA, MARY ANN (DNP,MSN,CWON,FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:NAMETKA
Suffix:
Gender:F
Credentials:DNP,MSN,CWON,FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7914 SE MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3031
Mailing Address - Country:US
Mailing Address - Phone:503-888-0390
Mailing Address - Fax:888-898-0933
Practice Address - Street 1:7914 SE MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3031
Practice Address - Country:US
Practice Address - Phone:503-888-0390
Practice Address - Fax:888-898-0933
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-06
Last Update Date:2024-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60063158363LF0000X
OR200750071NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily