Provider Demographics
NPI:1922485135
Name:WELLS, MARY CAITLIN (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:CAITLIN
Last Name:WELLS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12710 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3134
Mailing Address - Country:US
Mailing Address - Phone:503-988-5155
Mailing Address - Fax:503-988-5185
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:503-988-5155
Practice Address - Fax:503-988-5185
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201502244NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR22959Medicaid
OR096511Medicaid