Provider Demographics
NPI:1982991147
Name:WIKHOLM, LAUREN ILONA
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:ILONA
Last Name:WIKHOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 SE 91ST AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97086-3756
Mailing Address - Country:US
Mailing Address - Phone:971-801-1373
Mailing Address - Fax:
Practice Address - Street 1:9200 SE 91ST AVE
Practice Address - Street 2:STE 200
Practice Address - City:HAPPY VALLEY
Practice Address - State:OR
Practice Address - Zip Code:97086-3756
Practice Address - Country:US
Practice Address - Phone:971-801-1373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR72742208600000X
ORMD178101208600000X
WAMD60810172208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery