Provider Demographics
NPI:1255501805
Name:WORMDAHL, TANYA R (LMT)
Entity type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:R
Last Name:WORMDAHL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5553 NE GLISAN ST
Mailing Address - Street 2:300
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-3173
Mailing Address - Country:US
Mailing Address - Phone:503-757-3878
Mailing Address - Fax:
Practice Address - Street 1:5553 NE GLISAN ST
Practice Address - Street 2:300
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-3173
Practice Address - Country:US
Practice Address - Phone:503-757-3878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR11215174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist