Provider Demographics
NPI:1891249637
Name:VAN VALKENBURG, COURTNEY J (WHNP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:J
Last Name:VAN VALKENBURG
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:541-732-7460
Mailing Address - Fax:
Practice Address - Street 1:940 ROYAL AVE UNIT 350
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6194
Practice Address - Country:US
Practice Address - Phone:541-732-7460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-10
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95005129363LW0102X, 363LX0001X
OR202000861NP-PP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27958ZOtherGROUP MEDICARE PTAN
OR500805330Medicaid
CADQ488AOtherGROUP MEDICARE PTAN