Provider Demographics
NPI:1982304630
Name:FERNANDO, EMILY GRACE DOUGLASS (PNP)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:GRACE DOUGLASS
Last Name:FERNANDO
Suffix:
Gender:F
Credentials:PNP
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:
Practice Address - Street 1:830 NE 47TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2212
Practice Address - Country:US
Practice Address - Phone:503-216-2339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-09
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR100008582080P0008X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No2080P0008XAllopathic & Osteopathic PhysiciansPediatricsNeurodevelopmental Disabilities