Provider Demographics
NPI:1417393190
Name:CARMEN, SUSAN (RN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CARMEN
Suffix:
Gender:F
Credentials:RN
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 8459
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97207-8459
Mailing Address - Country:US
Mailing Address - Phone:503-238-0769
Mailing Address - Fax:
Practice Address - Street 1:847 NE 19TH AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2684
Practice Address - Country:US
Practice Address - Phone:503-528-0757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-21
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200441469RN163WP0808X
OR2004414691RN171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health