Provider Demographics
NPI:1730523788
Name:DERRY, KRISTEN ELAINE
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ELAINE
Last Name:DERRY
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 1:5105 SW ELM AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-4230
Mailing Address - Country:US
Mailing Address - Phone:541-659-9318
Mailing Address - Fax:
Practice Address - Street 1:12116 SE MILL PLAIN BLVD STE 1
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6000
Practice Address - Country:US
Practice Address - Phone:360-719-1512
Practice Address - Fax:503-254-0576
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-22
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3579ATI152W00000X
390200000X
WA60503088152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500740584Medicaid