Provider Demographics
NPI:1386636736
Name:LEATHERWOOD, AMY EIKO BERNEL (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:EIKO BERNEL
Last Name:LEATHERWOOD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 SW BOND AVE. CH10U
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239
Mailing Address - Country:US
Mailing Address - Phone:503-346-1500
Mailing Address - Fax:503-346-1501
Practice Address - Street 1:3303 SW BOND AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-346-1500
Practice Address - Fax:503-346-1501
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200350011NP363LF0000X
OR200340159RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9641440Medicaid
OR022498Medicaid
ORP94484Medicare UPIN
OR022498Medicaid