Provider Demographics
NPI:1720721392
Name:RATHBONE, DESIRAE DAWN (AG-ACNP-BC)
Entity Type:Individual
Prefix:
First Name:DESIRAE
Middle Name:DAWN
Last Name:RATHBONE
Suffix:
Gender:F
Credentials:AG-ACNP-BC
Other - Prefix:
Other - First Name:DESIRAE
Other - Middle Name:DAWN
Other - Last Name:RATHBONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DESIRAE LYMAN
Mailing Address - Street 1:PO BOX 2120
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2120
Mailing Address - Country:US
Mailing Address - Phone:541-274-6556
Mailing Address - Fax:541-274-6247
Practice Address - Street 1:2865 DAGGETT AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-1106
Practice Address - Country:US
Practice Address - Phone:541-274-6101
Practice Address - Fax:541-274-6106
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10002748363LA2100X
AZ273896363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care