Provider Demographics
NPI:1538315015
Name:MCCALLUM, COURTNEY ANN (APRN PMHNP)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:ANN
Last Name:MCCALLUM
Suffix:
Gender:F
Credentials:APRN PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14305 SW 112TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3705
Mailing Address - Country:US
Mailing Address - Phone:503-660-2418
Mailing Address - Fax:
Practice Address - Street 1:14305 SW 112TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97224-3705
Practice Address - Country:US
Practice Address - Phone:503-660-2418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-15
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200841828RN163WM0705X
OR10025683363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical