Provider Demographics
NPI:1053002758
Name:PRESLEY, TERRA
Entity type:Individual
Prefix:
First Name:TERRA
Middle Name:
Last Name:PRESLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 SW PARK AVE STE 304
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-3204
Mailing Address - Country:US
Mailing Address - Phone:971-236-2612
Mailing Address - Fax:
Practice Address - Street 1:519 SW PARK AVE STE 304
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-3204
Practice Address - Country:US
Practice Address - Phone:971-236-2612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2024-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
OR374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500824206Medicaid