Provider Demographics
NPI:1619404316
Name:DIMAKU, VIKTORIYA MIKHAYLOVNA (FNP)
Entity Type:Individual
Prefix:
First Name:VIKTORIYA
Middle Name:MIKHAYLOVNA
Last Name:DIMAKU
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:VIKTORIYA
Other - Middle Name:MIKHAYLOVNA
Other - Last Name:CHEPEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:6125 SW BOUNDARY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-1019
Mailing Address - Country:US
Mailing Address - Phone:971-319-3499
Mailing Address - Fax:
Practice Address - Street 1:7689 SW CAPITOL HWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2475
Practice Address - Country:US
Practice Address - Phone:971-319-3562
Practice Address - Fax:877-771-0997
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201703002NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily