Provider Demographics
NPI:1902261340
Name:WYLDE, DAWN L (RN/QMHP-C)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:L
Last Name:WYLDE
Suffix:
Gender:F
Credentials:RN/QMHP-C
Other - Prefix:
Other - First Name:DAWN
Other - Middle Name:L
Other - Last Name:CRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN/QMHP-C
Mailing Address - Street 1:1776 SW MADISON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1715
Mailing Address - Country:US
Mailing Address - Phone:503-224-1044
Mailing Address - Fax:503-621-2235
Practice Address - Street 1:17645 NW SAINT HELENS RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97231-1729
Practice Address - Country:US
Practice Address - Phone:503-621-1069
Practice Address - Fax:503-621-0200
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR23-QMHPC-001204101YM0800X
WARN60392843163W00000X
OR201401462RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500798396Medicaid
WA2075923Medicaid