Provider Demographics
NPI:1619481744
Name:FITZ GERALD, NAN ISABEL (RN CDE)
Entity Type:Individual
Prefix:MS
First Name:NAN
Middle Name:ISABEL
Last Name:FITZ GERALD
Suffix:
Gender:F
Credentials:RN CDE
Other - Prefix:MS
Other - First Name:NAN
Other - Middle Name:I
Other - Last Name:FITZ GERALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:087006811RN
Mailing Address - Street 1:1040 NW 22ND AVE STE 540
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3097
Mailing Address - Country:US
Mailing Address - Phone:503-413-6077
Mailing Address - Fax:503-413-6888
Practice Address - Street 1:1040 NW 22ND AVE STE 540
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3097
Practice Address - Country:US
Practice Address - Phone:503-413-6077
Practice Address - Fax:503-413-6888
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR087006811RN163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator