Provider Demographics
NPI:1144211913
Name:ANDERSON, CARLA RAYNE (FNP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:RAYNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:R
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C
Mailing Address - Street 1:31130 SW WALLOWA CT
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9778
Mailing Address - Country:US
Mailing Address - Phone:503-855-3789
Mailing Address - Fax:503-570-3367
Practice Address - Street 1:30250 SW PARKWAY AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9757
Practice Address - Country:US
Practice Address - Phone:503-570-3366
Practice Address - Fax:503-570-3367
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250170NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR200250170NPOtherOREGON NP LICENSE
OR200250170NPOtherOREGON NP LICENSE