Provider Demographics
NPI:1053180497
Name:DERR, EILEEN ALICE
Entity type:Individual
Prefix:
First Name:EILEEN
Middle Name:ALICE
Last Name:DERR
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 1:3530 SE 88TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-2396
Mailing Address - Country:US
Mailing Address - Phone:509-225-3396
Mailing Address - Fax:
Practice Address - Street 1:3530 SE 88TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-2396
Practice Address - Country:US
Practice Address - Phone:509-225-3396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker