Provider Demographics
NPI:1114479250
Name:EMILY GANNAWAY, LLC
Entity Type:Organization
Organization Name:EMILY GANNAWAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATUROPATHIC DOCTOR/PCP
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:GANNAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:ND
Authorized Official - Phone:201-213-2112
Mailing Address - Street 1:1507 9TH ST
Mailing Address - Street 2:APT 12
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-2073
Mailing Address - Country:US
Mailing Address - Phone:201-213-2112
Mailing Address - Fax:
Practice Address - Street 1:17933 NW EVERGREEN PKWY
Practice Address - Street 2:SUITE 285
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-7659
Practice Address - Country:US
Practice Address - Phone:503-828-9265
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3092175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty