Provider Demographics
NPI:1295275113
Name:VESELY, COURTNEY LANE (NP-C)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:LANE
Last Name:VESELY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:LANE
Other - Last Name:NORDINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6325 NE 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-1330
Mailing Address - Country:US
Mailing Address - Phone:605-431-5376
Mailing Address - Fax:
Practice Address - Street 1:4035 MERCANTILE DR STE 101
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-2587
Practice Address - Country:US
Practice Address - Phone:503-697-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201702901NP-PP363LF0000X
SDR041703163W00000X
OR201701633RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse