Provider Demographics
NPI:1578575775
Name:HARRIS, KRISTEN ANN (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9340 SW BARNES RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-6623
Mailing Address - Country:US
Mailing Address - Phone:503-297-6334
Mailing Address - Fax:503-297-2360
Practice Address - Street 1:4805 NE GLISAN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2933
Practice Address - Country:US
Practice Address - Phone:503-297-6334
Practice Address - Fax:503-297-2360
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR091006892N1 FNP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR291747Medicaid
ORR153078Medicare PIN
ORR153812Medicare PIN
ORR152879Medicare PIN
ORR154023Medicare PIN
ORR136137Medicare PIN
ORP01000Medicare UPIN
OR291747Medicaid
ORR157321Medicare PIN
ORR153811Medicare PIN
OR114675Medicare ID - Type Unspecified
ORR151579Medicare PIN
ORR153810Medicare PIN