Provider Demographics
NPI:1518678606
Name:LEAIR, PENELOPE ROXAS
Entity Type:Individual
Prefix:
First Name:PENELOPE
Middle Name:ROXAS
Last Name:LEAIR
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 1:4314 SW VESTA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-7453
Mailing Address - Country:US
Mailing Address - Phone:847-840-9707
Mailing Address - Fax:
Practice Address - Street 1:10860 SE OAK ST
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-6694
Practice Address - Country:US
Practice Address - Phone:503-652-8058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201142524RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse