Provider Demographics
NPI:1619993433
Name:SCHOEPPNER, KELLY (ANP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SCHOEPPNER
Suffix:
Gender:F
Credentials:ANP
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:
Mailing Address - Fax:
Practice Address - Street 1:420 NE MASON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97211-3479
Practice Address - Country:US
Practice Address - Phone:503-546-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00128492163WH1000X
WAAP30004389163WH1000X, 363L00000X
OR201392002NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WH1000XNursing Service ProvidersRegistered NurseHospice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0209727OtherSTATE L&I
WA0209727OtherL&I
WA8941623OtherSTATE CRIME VICTIMS
WA9626268Medicaid
WA8941623OtherSTATE CRIME VICTIMS
WA9626268Medicaid
WAG8860935Medicare PIN
S97627Medicare UPIN
WA0209727OtherSTATE L&I