Provider Demographics
NPI:1326737735
Name:RICHARDSON, GENEVA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:GENEVA
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials: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 2392
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023-2392
Mailing Address - Country:US
Mailing Address - Phone:503-830-1622
Mailing Address - Fax:
Practice Address - Street 1:13043 SE 84TH AVE
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9798
Practice Address - Country:US
Practice Address - Phone:971-930-5582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10008926363L00000X
WAAP61432615363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner