Provider Demographics
NPI:1811603079
Name:RONQUILLO, STACY (NP)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:RONQUILLO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2411
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-2411
Mailing Address - Country:US
Mailing Address - Phone:503-208-4610
Mailing Address - Fax:
Practice Address - Street 1:9455 SW 80TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8966
Practice Address - Country:US
Practice Address - Phone:503-208-4610
Practice Address - Fax:503-447-2700
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10012143363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care