Provider Demographics
NPI:1194821751
Name:CALLAHAN, LAURIE LEIGH (MSN, FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:LEIGH
Last Name:CALLAHAN
Suffix:
Gender:F
Credentials:MSN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-734-7460
Mailing Address - Fax:541-732-7461
Practice Address - Street 1:940 ROYAL AVE UNIT 350
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6194
Practice Address - Country:US
Practice Address - Phone:541-732-7460
Practice Address - Fax:541-734-7461
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200650147NP363LF0000X
OR095006655163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR292038Medicaid
OR136896Medicare PIN
ORQ73648Medicare UPIN
OR135811Medicare PIN