Provider Demographics
NPI:1982041703
Name:GWYNN, KIRSTEN (CNM)
Entity Type:Individual
Prefix:MS
First Name:KIRSTEN
Middle Name:
Last Name:GWYNN
Suffix:
Gender:F
Credentials:CNM
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 3777
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3777
Mailing Address - Country:US
Mailing Address - Phone:503-413-3900
Mailing Address - Fax:503-413-3710
Practice Address - Street 1:24850 SE STARK ST STE 200
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8320
Practice Address - Country:US
Practice Address - Phone:503-491-9444
Practice Address - Fax:503-661-3430
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMW010305367A00000X
OR201405814NP-PP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMW010305OtherNURSE-MIDWIFE LICENSE