Provider Demographics
NPI:1114361110
Name:DOLAN, STEPHANIE IWALANI (PNP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:IWALANI
Last Name:DOLAN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:IWALANI
Other - Last Name:RIVERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 SW COLUMBIA ST
Mailing Address - Street 2:SUITE 6210
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1099
Mailing Address - Country:US
Mailing Address - Phone:541-383-3005
Mailing Address - Fax:
Practice Address - Street 1:1314 SW KALAMA AVE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-3054
Practice Address - Country:US
Practice Address - Phone:541-923-5800
Practice Address - Fax:541-383-1883
Is Sole Proprietor?:No
Enumeration Date:2013-04-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201609258NP-PP363LP0200X, 363LP0200X
VA0024169839363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500718029Medicaid