Provider Demographics
NPI:1780066514
Name:GWARTNEY, AMY BURKE (LMT #20514)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:BURKE
Last Name:GWARTNEY
Suffix:
Gender:F
Credentials:LMT #20514
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1842 NW 25TH AVE
Mailing Address - Street 2:#1
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210
Mailing Address - Country:US
Mailing Address - Phone:503-593-1399
Mailing Address - Fax:
Practice Address - Street 1:1842 NW 25TH AVE
Practice Address - Street 2:#1
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-593-1399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20514172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker