Provider Demographics
NPI:1437488541
Name:WALLAERT, SUMMER NICOLE
Entity Type:Individual
Prefix:MRS
First Name:SUMMER
Middle Name:NICOLE
Last Name:WALLAERT
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 1:1500 SW PLEASANT VIEW DR APT 314
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97080-7776
Mailing Address - Country:US
Mailing Address - Phone:805-610-7219
Mailing Address - Fax:
Practice Address - Street 1:1500 NE IRVING ST
Practice Address - Street 2:SUITE 250
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2243
Practice Address - Country:US
Practice Address - Phone:503-233-4356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator