Provider Demographics
NPI:1649699455
Name:BORBA SPANN, KACY LEANN (ND, LAC)
Entity type:Individual
Prefix:DR
First Name:KACY
Middle Name:LEANN
Last Name:BORBA SPANN
Suffix:
Gender:F
Credentials:ND, LAC
Other - Prefix:DR
Other - First Name:KACY
Other - Middle Name:LEANN
Other - Last Name:BORBA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ND, LAC
Mailing Address - Street 1:3942 SE HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5242
Mailing Address - Country:US
Mailing Address - Phone:971-258-1853
Mailing Address - Fax:
Practice Address - Street 1:3942 SE HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-5242
Practice Address - Country:US
Practice Address - Phone:712-581-8539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-08
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC167588171100000X
OR20290174400000X
OR2022175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500688613Medicaid
OR500680362Medicaid