Provider Demographics
NPI:1659653277
Name:AMLIN, TRACEY DIONA (FNP)
Entity Type:Individual
Prefix:
First Name:TRACEY
Middle Name:DIONA
Last Name:AMLIN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TRACEY
Other - Middle Name:DIONA
Other - Last Name:SINCLAIR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4340 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-3211
Practice Address - Country:US
Practice Address - Phone:503-215-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-10
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH12645NP363LF0000X
OR201505843NP-PP363LF0000X
WAAP60645755363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500699841Medicaid
ORR187451Medicare PIN
ORR187452Medicare PIN
ORR187453Medicare PIN
ORR186583Medicare PIN
ORR187454Medicare PIN
OR500699841Medicaid
ORR188372Medicare PIN