Provider Demographics
NPI:1285625988
Name:THAANUM, ELIZABETH DANIELLE
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:DANIELLE
Last Name:THAANUM
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELIZABETH
Other - Middle Name:DANIELLE
Other - Last Name:TANGEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-A
Mailing Address - Street 1:1401 UPPER APPLEGATE RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9179
Mailing Address - Country:US
Mailing Address - Phone:541-899-2007
Mailing Address - Fax:
Practice Address - Street 1:42 HAWTHORNE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7114
Practice Address - Country:US
Practice Address - Phone:541-776-3461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22174237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR858535002OtherBCBS OF OREGON PROV. #
ORJ133302OtherPACIFICSOURCE PIN NUMBER
OR002387312-002OtherUNITEDHEALTHCARE PROV. #
OR408242302OtherPREF. CHOICE 65 PROV. #
OR226610Medicaid
OR132376Medicare PIN