Provider Demographics
NPI:1851637383
Name:HARGETT, MARILYN SOPHIA
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:SOPHIA
Last Name:HARGETT
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 1:619 NW 6TH AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3964
Mailing Address - Country:US
Mailing Address - Phone:503-887-5665
Mailing Address - Fax:
Practice Address - Street 1:12710 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3134
Practice Address - Country:US
Practice Address - Phone:503-988-3601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2020-01-24
Deactivation Date:2018-03-29
Deactivation Code:
Reactivation Date:2018-04-11
Provider Licenses
StateLicense IDTaxonomies
OR201802206NP363L00000X, 363L00000X
OR200941774RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201802206NPOtherSTATE LICENSE