Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | DEM-LD-10163507 | OR |
NPI | 1124434253 |
---|---|
Provider Name | Mrs. Tara Rochelle Kolberg |
First Address | Portland, OR 97203-6017 |
Second Address | Portland, OR 97214-1448 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/07/2014 |
Last Update Date | 09/07/2014 |