Basic Information
| Provider Information | |||||||||
| NPI: | 1558566745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALDWELL | ||||||||
| FirstName: | PENELOPE | ||||||||
| MiddleName: | RUTH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | C.N.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 847 NE 19TH AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972322684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039632801 | ||||||||
| FaxNumber: | 5039963282 | ||||||||
| Practice Location | |||||||||
| Address1: | 5050 NE HOYT ST | ||||||||
| Address2: | SUITE 353 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972132991 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032396800 | ||||||||
| FaxNumber: | 5032390006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2007 | ||||||||
| LastUpdateDate: | 01/02/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 19617.0716 | WY | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | 201350088NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 500672435 | 05 | OR | MEDICAID |