Basic Information
| Provider Information | |||||||||
| NPI: | 1619562170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAMAZO | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3303 S BOND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034941775 | ||||||||
| FaxNumber: | 5034944749 | ||||||||
| Practice Location | |||||||||
| Address1: | 3303 S BOND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972394501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034941775 | ||||||||
| FaxNumber: | 5034944749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2021 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 2020012418 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LS0200X | 2020012418 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | School | 363LF0000X | 202011147NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.