Provider Demographics
NPI:1124015631
Name:KELLOGG-GRATCHNER, CHRISTINA E (PNP)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:E
Last Name:KELLOGG-GRATCHNER
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4084
Mailing Address - Country:US
Mailing Address - Phone:503-640-2757
Mailing Address - Fax:503-640-9753
Practice Address - Street 1:445 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97123-4084
Practice Address - Country:US
Practice Address - Phone:503-640-2757
Practice Address - Fax:503-640-9753
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR086000482363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
R167202OtherPTAN
OR000458Medicaid
OR108591Medicare ID - Type Unspecified