Provider Demographics
NPI:1831152032
Name:VINING, RETA L (ANP-BC)
Entity type:Individual
Prefix:MS
First Name:RETA
Middle Name:L
Last Name:VINING
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:MS
Other - First Name:RETA
Other - Middle Name:L
Other - Last Name:VINING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2440 HARTMAN LANE
Mailing Address - Street 2:200
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97877
Mailing Address - Country:US
Mailing Address - Phone:541-205-1192
Mailing Address - Fax:
Practice Address - Street 1:2440 HARTMAN LANE
Practice Address - Street 2:200
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97877
Practice Address - Country:US
Practice Address - Phone:541-205-1192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450030NP ANP PP363LA2200X
MO2011031615363LA2200X
WA60081469363LA2200X
OH08652363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0864364Medicaid
OR0864364Medicaid
9361031Medicare PIN