Provider Demographics
NPI:1851394464
Name:KITTLESON, BONNIE K (FNP)
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:K
Last Name:KITTLESON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 SE MAIN ST STE 350
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2474
Mailing Address - Country:US
Mailing Address - Phone:971-262-9800
Mailing Address - Fax:971-262-9899
Practice Address - Street 1:10000 SE MAIN ST STE 350
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2474
Practice Address - Country:US
Practice Address - Phone:971-262-9800
Practice Address - Fax:971-262-9899
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450048NP363L00000X, 363LF0000X
ID53108363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q-19844Medicare UPIN
ORCV0082OtherRR MEDICARE GROUP NUMBER
119655Medicare ID - Type Unspecified
OR275409Medicaid