Provider Demographics
NPI:1477259430
Name:EBERT, KONNIE JOANNE (BSN)
Entity Type:Individual
Prefix:
First Name:KONNIE
Middle Name:JOANNE
Last Name:EBERT
Suffix:
Gender:F
Credentials:BSN
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 1200
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023-1200
Mailing Address - Country:US
Mailing Address - Phone:503-630-5511
Mailing Address - Fax:503-630-5513
Practice Address - Street 1:200 SE HIGHWAY 224
Practice Address - Street 2:
Practice Address - City:ESTACADA
Practice Address - State:OR
Practice Address - Zip Code:97224
Practice Address - Country:US
Practice Address - Phone:503-630-5511
Practice Address - Fax:503-630-5513
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200941730RN163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management