Provider Demographics
NPI:1366009151
Name:VILLANUEVA, MARIAH L
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:L
Last Name:VILLANUEVA
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 1:13930N SE BUSH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-2942
Mailing Address - Country:US
Mailing Address - Phone:509-280-0586
Mailing Address - Fax:
Practice Address - Street 1:4400 NE HALSEY ST BLDG 2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1545
Practice Address - Country:US
Practice Address - Phone:503-893-6472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker