Provider Demographics
NPI:1619966801
Name:HARLAN, ELAINE MARY (FNP)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:MARY
Last Name:HARLAN
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 1:1255 WALLACE RD NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3007
Mailing Address - Country:US
Mailing Address - Phone:503-362-1314
Mailing Address - Fax:503-362-5895
Practice Address - Street 1:1255 WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3007
Practice Address - Country:US
Practice Address - Phone:503-362-1314
Practice Address - Fax:503-362-5895
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278804Medicaid
ORR105621Medicare PIN
OR278804Medicaid