Provider Demographics
NPI:1770524480
Name:KINZIE, AMY KARYL (ANP)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KARYL
Last Name:KINZIE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 SE MAIN ST
Mailing Address - Street 2:#1001
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2455
Mailing Address - Country:US
Mailing Address - Phone:503-255-3404
Mailing Address - Fax:503-255-4750
Practice Address - Street 1:10101 SE MAIN ST
Practice Address - Street 2:#1001
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2455
Practice Address - Country:US
Practice Address - Phone:503-255-3404
Practice Address - Fax:503-255-4750
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR090007080N3363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORP32409Medicare UPIN
ORR151500Medicare PIN