Provider Demographics
NPI:1457012791
Name:BALANETSKAYA, DARYA (NP)
Entity Type:Individual
Prefix:
First Name:DARYA
Middle Name:
Last Name:BALANETSKAYA
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 1:5622 SE 52ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-5654
Mailing Address - Country:US
Mailing Address - Phone:503-944-9400
Mailing Address - Fax:
Practice Address - Street 1:6800 SW 105TH AVE STE 206
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-5487
Practice Address - Country:US
Practice Address - Phone:503-430-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201504283RN163W00000X
OR202206690NP-PP363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care