Provider Demographics
NPI:1336804319
Name:BOETTCHER, INGRID MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:INGRID
Middle Name:MARIE
Last Name:BOETTCHER
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 1:40933 OLD HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-8684
Mailing Address - Country:US
Mailing Address - Phone:503-298-8296
Mailing Address - Fax:
Practice Address - Street 1:1150 N ROOSEVELT DR APT 104
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:OR
Practice Address - Zip Code:97138-7053
Practice Address - Country:US
Practice Address - Phone:503-717-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201141723RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse