Provider Demographics
NPI:1760144166
Name:OREGON PSYCH NP, LLC
Entity Type:Organization
Organization Name:OREGON PSYCH NP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:BUTLER
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:541-382-1395
Mailing Address - Street 1:61331 WARD RD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9619
Mailing Address - Country:US
Mailing Address - Phone:503-853-9356
Mailing Address - Fax:
Practice Address - Street 1:339 SW CENTURY DR STE 101
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1199
Practice Address - Country:US
Practice Address - Phone:541-382-1395
Practice Address - Fax:541-382-6576
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OREGON PSYCH NP, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578934535OtherNPI