Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 152W00000X | Optometrist | 3649ATI | OR |
NPI | 1003168337 |
---|---|
Provider Name | Mrs. Ayla Jade Himmelsbach |
First Address | Portland, OR 97219-2466 |
Second Address | Portland, OR 97219-2466 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2012 |
Last Update Date | 04/11/2021 |