Provider Demographics
NPI:1417095241
Name:MOREN, SHERYL ROSALES (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:SHERYL
Middle Name:ROSALES
Last Name:MOREN
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 SE WOODSTOCK BLVD # 286
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6267
Mailing Address - Country:US
Mailing Address - Phone:503-714-6481
Mailing Address - Fax:503-894-7972
Practice Address - Street 1:2029 SE JEFFERSON ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7605
Practice Address - Country:US
Practice Address - Phone:503-714-6481
Practice Address - Fax:503-894-7972
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200241621RN163W00000X
OR200450025NP PMHNP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR025187Medicaid
ORQ47989Medicare UPIN
OR131961Medicare PIN