Provider Demographics
NPI:1942623764
Name:HALLOCK KOPPELMAN, LAUREL KATHERINE (FNP-C)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:KATHERINE
Last Name:HALLOCK KOPPELMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 SW OAK ST
Mailing Address - Street 2:STE. 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-3015
Practice Address - Street 1:12720 SE DIVISION STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236
Practice Address - Country:US
Practice Address - Phone:503-988-3601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201392556363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR22959Medicaid
OR096511Medicaid