Provider Demographics
NPI:1770932097
Name:IVERSEN, HALLIE
Entity type:Individual
Prefix:
First Name:HALLIE
Middle Name:
Last Name:IVERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3587 HEATHROW WAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4004
Mailing Address - Country:US
Mailing Address - Phone:541-858-8170
Mailing Address - Fax:
Practice Address - Street 1:100 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-6041
Practice Address - Country:US
Practice Address - Phone:541-200-2900
Practice Address - Fax:541-200-2948
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2017-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201408131163WP0808X
NMR43397163WP0808X
TX715035163WP0808X
OR201408131RN163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health