Provider Demographics
NPI:1871639641
Name:KORNBLUM, ROBERTA (RN)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:
Last Name:KORNBLUM
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 1:13333 S GLENN DR
Mailing Address - Street 2:
Mailing Address - City:MULINO
Mailing Address - State:OR
Mailing Address - Zip Code:97042-9635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3034 NE M L KING BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3053
Practice Address - Country:US
Practice Address - Phone:503-283-3763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR086006572RN163W00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator