Provider Demographics
NPI:1649649641
Name:KHNG, ROSEMARIE E (RN/QMHP)
Entity type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:E
Last Name:KHNG
Suffix:
Gender:F
Credentials:RN/QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:1438 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1140
Practice Address - Country:US
Practice Address - Phone:503-548-0346
Practice Address - Fax:503-232-5959
Is Sole Proprietor?:No
Enumeration Date:2015-09-20
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR081001086RN163W00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500711513Medicaid