Provider Demographics
NPI:1548504566
Name:RIST, AMY JO (CPM, LDM)
Entity type:Individual
Prefix:
First Name:AMY JO
Middle Name:
Last Name:RIST
Suffix:
Gender:F
Credentials:CPM, LDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 SE HAWTHORNE BLVD # 267
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-5246
Mailing Address - Country:US
Mailing Address - Phone:503-652-8076
Mailing Address - Fax:503-922-0080
Practice Address - Street 1:2928 SE HAWTHORNE BLVD STE 107
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-4147
Practice Address - Country:US
Practice Address - Phone:503-652-8076
Practice Address - Fax:503-922-0080
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10151742176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife