Provider Demographics
NPI:1609067677
Name:DEA, MARILEE (NP)
Entity Type:Individual
Prefix:
First Name:MARILEE
Middle Name:
Last Name:DEA
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 1:426 SW STARK ST
Mailing Address - Street 2:8TH FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-2347
Mailing Address - Country:US
Mailing Address - Phone:503-988-3056
Mailing Address - Fax:503-988-5182
Practice Address - Street 1:426 SW STARK ST
Practice Address - Street 2:8TH FLOOR
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97204-2347
Practice Address - Country:US
Practice Address - Phone:503-988-3056
Practice Address - Fax:503-988-5182
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000030062N2363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR285171Medicaid
OR285171Medicaid
OR105574Medicare PIN