Provider Demographics
NPI:1174792998
Name:MOORE, MINDY MILAR (PMHNP)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:MILAR
Last Name:MOORE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8959 SW BARBUR BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-4032
Mailing Address - Country:US
Mailing Address - Phone:888-667-6467
Mailing Address - Fax:888-667-6467
Practice Address - Street 1:7975 SW 83RD AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-7334
Practice Address - Country:US
Practice Address - Phone:888-667-6467
Practice Address - Fax:888-667-6467
Is Sole Proprietor?:No
Enumeration Date:2008-02-26
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR50112NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
50112NPOtherOREGON BOARD OF NURSING
OR500623422Medicaid
OR102124BMedicare PIN