Provider Demographics
NPI:1730712290
Name:BLOEDON, LUCY ANNE
Entity type:Individual
Prefix:
First Name:LUCY
Middle Name:ANNE
Last Name:BLOEDON
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 1:4020 SW IOWA ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97221-3423
Mailing Address - Country:US
Mailing Address - Phone:503-577-9504
Mailing Address - Fax:
Practice Address - Street 1:4020 SW IOWA ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-3423
Practice Address - Country:US
Practice Address - Phone:503-577-9504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20200141NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health