Provider Demographics
NPI:1740793579
Name:HARRIS, KATIE LYNN
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2808 SE 59TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-1452
Mailing Address - Country:US
Mailing Address - Phone:510-847-1389
Mailing Address - Fax:
Practice Address - Street 1:830 NE 47TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2212
Practice Address - Country:US
Practice Address - Phone:503-215-2429
Practice Address - Fax:503-215-2429
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist