Basic Information
| Provider Information | |||||||||
| NPI: | 1588216519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | NELLIE | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 22009 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972692009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035587372 | ||||||||
| FaxNumber: | 5033445140 | ||||||||
| Practice Location | |||||||||
| Address1: | 10819 SE STARK ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972163161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032552291 | ||||||||
| FaxNumber: | 5032521797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2019 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OD60961378 | WA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | ATI4496 | OR | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | ATI4496 | 01 | OR | OR STATE LICENSE | OTHER |