Basic Information
Provider Information | |||||||||
NPI: | 1033190574 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HANLON-WILDE | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | F.N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HANLON | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MRS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | F.N.P. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1520 | ||||||||
Address2: |   | ||||||||
City: | THE DALLES | ||||||||
State: | OR | ||||||||
PostalCode: | 970588003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412965657 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1810 E 19TH ST | ||||||||
Address2: | SUITE 209 | ||||||||
City: | THE DALLES | ||||||||
State: | OR | ||||||||
PostalCode: | 970583388 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412965657 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/10/2005 | ||||||||
LastUpdateDate: | 02/16/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 098006694NP | OR | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LW0102X | 098006694RN FNP-PP | OR | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
ID | Type | State | Issuer | Description | 092586 | 05 | OR |   | MEDICAID |