Provider Demographics
NPI:1275840936
Name:ESTEGHLALIAN, LEILY (STUDENT)
Entity Type:Individual
Prefix:MRS
First Name:LEILY
Middle Name:
Last Name:ESTEGHLALIAN
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 N WILLAMETTE BLVD
Mailing Address - Street 2:BC382
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5743
Mailing Address - Country:US
Mailing Address - Phone:503-943-7266
Mailing Address - Fax:
Practice Address - Street 1:5000 N WILLAMETTE BLVD
Practice Address - Street 2:BC382
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-5743
Practice Address - Country:US
Practice Address - Phone:503-943-7266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR098000406390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR098000406OtherOREGON STATE BOARD OF NURSIN