Provider Demographics
NPI:1881944973
Name:LAVELLE, MARY BERNADETTE (RN, MSN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BERNADETTE
Last Name:LAVELLE
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118 SE RURAL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-7845
Mailing Address - Country:US
Mailing Address - Phone:503-777-6151
Mailing Address - Fax:
Practice Address - Street 1:4118 SE RURAL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-7845
Practice Address - Country:US
Practice Address - Phone:503-777-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-15
Last Update Date:2012-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000035593RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse