Provider Demographics
NPI:1144776899
Name:PEMBERTON, VICKIE
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:PEMBERTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17540 BROWN RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-9375
Mailing Address - Country:US
Mailing Address - Phone:503-949-1449
Mailing Address - Fax:
Practice Address - Street 1:17540 BROWN RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-9375
Practice Address - Country:US
Practice Address - Phone:503-949-1449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR333228224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant