Provider Demographics
NPI:1750897252
Name:HURT, ROBERTA JEAN (LPN)
Entity type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:JEAN
Last Name:HURT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:ROBERTA
Other - Middle Name:JEAN
Other - Last Name:PRIEST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4925 SW 45TH AVE APT 15
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-3663
Mailing Address - Country:US
Mailing Address - Phone:503-317-5317
Mailing Address - Fax:
Practice Address - Street 1:2600 SE BELMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-2916
Practice Address - Country:US
Practice Address - Phone:503-843-8823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200170096LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse