Provider Demographics
NPI:1760091839
Name:HUMPHRIES, PEGGY LYNN
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:LYNN
Last Name:HUMPHRIES
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 1:5042 S CORBETT AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3944
Mailing Address - Country:US
Mailing Address - Phone:925-812-4201
Mailing Address - Fax:
Practice Address - Street 1:10700 SW BEAVERTON HILLSDALE HWY BLDG 1
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3019
Practice Address - Country:US
Practice Address - Phone:503-645-9010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-CRM-138175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist