Provider Demographics
NPI:1790973840
Name:BROCKMEYER, ERIN KATE FELLENZ (LAC)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:KATE FELLENZ
Last Name:BROCKMEYER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:KATE
Other - Last Name:FELLENZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:9955 SE WASHINGTON ST STE 320
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2439
Mailing Address - Country:US
Mailing Address - Phone:503-253-8818
Mailing Address - Fax:503-253-0377
Practice Address - Street 1:9955 SE WASHINGTON ST STE 320
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2439
Practice Address - Country:US
Practice Address - Phone:503-253-8818
Practice Address - Fax:503-253-0377
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC01074171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist