Provider Demographics
NPI:1821547985
Name:ROOSE, KATHERINE (CPNP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:ROOSE
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:ZACKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CPNP
Mailing Address - Street 1:8645 SE SUNNYBROOK BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:CLACKAMAS
Mailing Address - State:OR
Mailing Address - Zip Code:97015-6841
Mailing Address - Country:US
Mailing Address - Phone:503-659-1694
Mailing Address - Fax:
Practice Address - Street 1:8645 SE SUNNYBROOK BLVD STE 200
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6841
Practice Address - Country:US
Practice Address - Phone:503-659-1694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201608030NP-PP363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics