Provider Demographics
NPI:1366228264
Name:KING, CHARISA ANN (APRN-NP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:CHARISA
Middle Name:ANN
Last Name:KING
Suffix:
Gender:F
Credentials:APRN-NP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17617 SYDNI CT
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5588
Mailing Address - Country:US
Mailing Address - Phone:435-850-9535
Mailing Address - Fax:
Practice Address - Street 1:6647 SE MILWAUKIE AVE STE B210
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-5661
Practice Address - Country:US
Practice Address - Phone:971-258-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-06
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR100152363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health