Provider Demographics
NPI:1649444191
Name:AVALON, KRISHNA KARIANN (LAC)
Entity type:Individual
Prefix:
First Name:KRISHNA
Middle Name:KARIANN
Last Name:AVALON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:KRISHNA
Other - Middle Name:KARIANN
Other - Last Name:BADER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4816 NE GOING ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97218-2004
Mailing Address - Country:US
Mailing Address - Phone:503-522-2872
Mailing Address - Fax:
Practice Address - Street 1:4605 NE FREMONT ST
Practice Address - Street 2:STE 103
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1707
Practice Address - Country:US
Practice Address - Phone:503-522-2872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-16
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000612171100000X
ORAC01299171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist