Provider Demographics
NPI:1346924446
Name:KULLA, MARIA KAY
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:KAY
Last Name:KULLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44995 SE PAHA LOOP DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-9424
Mailing Address - Country:US
Mailing Address - Phone:503-929-7971
Mailing Address - Fax:
Practice Address - Street 1:24900 SE STARK ST
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3355
Practice Address - Country:US
Practice Address - Phone:503-413-7162
Practice Address - Fax:503-674-4140
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0008589363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily