Provider Demographics
NPI:1932749173
Name:DRAKE, TREVA SAKURA
Entity Type:Individual
Prefix:
First Name:TREVA
Middle Name:SAKURA
Last Name:DRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TREVA
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:232 NW 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3609
Mailing Address - Country:US
Mailing Address - Phone:503-294-1681
Mailing Address - Fax:
Practice Address - Street 1:1111 NW NAITO PKWY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2596
Practice Address - Country:US
Practice Address - Phone:503-488-7720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201909401RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse