Provider Demographics
NPI:1720441470
Name:LUND, EMILY ELIZABETH (LPN)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ELIZABETH
Last Name:LUND
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:EMILY
Other - Middle Name:ELIZABETH
Other - Last Name:KOSMECKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ZIMMERMAN
Mailing Address - Street 1:35630 ELK MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENS
Mailing Address - State:OR
Mailing Address - Zip Code:97051-3753
Mailing Address - Country:US
Mailing Address - Phone:503-919-5821
Mailing Address - Fax:
Practice Address - Street 1:324 NW DAVIS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3925
Practice Address - Country:US
Practice Address - Phone:503-226-2203
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201504087LPN261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR028382Medicaid