Provider Demographics
NPI:1700967437
Name:MCKIMMY, MANDY W (DNP, FNP)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:W
Last Name:MCKIMMY
Suffix:
Gender:F
Credentials:DNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 SE BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2817
Mailing Address - Country:US
Mailing Address - Phone:503-445-7699
Mailing Address - Fax:503-802-0199
Practice Address - Street 1:19761 BEAVERCREEK RD
Practice Address - Street 2:
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-9557
Practice Address - Country:US
Practice Address - Phone:503-785-8770
Practice Address - Fax:503-785-8543
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201150038NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G5647Medicare PIN
TXQ20161Medicare UPIN