Provider Demographics
NPI:1205828936
Name:GRISWOLD, ROXANNE RUYLE (FNP)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:RUYLE
Last Name:GRISWOLD
Suffix:
Gender:F
Credentials:FNP
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:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:STE 6N40
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-215-5696
Practice Address - Fax:503-215-5695
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20005003NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100121Medicaid
OR100121Medicaid
ORP81807Medicare UPIN
OR116311Medicare ID - Type Unspecified