Provider Demographics
NPI:1871032375
Name:BODEN, ROBERTA J (RN)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:J
Last Name:BODEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:971-386-2278
Mailing Address - Fax:503-224-4494
Practice Address - Street 1:12360 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1042
Practice Address - Country:US
Practice Address - Phone:971-279-4800
Practice Address - Fax:971-279-2051
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200140406RN163W00000X
WARN00130190163W00000X
CA562816163W00000X
IL041281908163W00000X
HIRN-48557163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse