Provider Demographics
NPI:1861507279
Name:KLESH, MARYLYN R (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:MARYLYN
Middle Name:R
Last Name:KLESH
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 SW WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-3460
Mailing Address - Country:US
Mailing Address - Phone:503-249-3434
Mailing Address - Fax:
Practice Address - Street 1:4855 SW WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-3460
Practice Address - Country:US
Practice Address - Phone:503-643-7565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000024615N6163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health