Individual
LYNDSAY PROVENCIO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PT
Contact information
Practice address
4829 NE MLK JR BLVD STE 101, PORTLAND, OR 97211-3491
(503) 283-8133
(503) 287-0245
Mailing address
16083 SW UPPER BOONES FERRY RD STE 300, TIGARD, OR 97224-7736
(503) 443-6156
(503) 639-9699
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
62930
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500749429
—
OR
Enumeration date
08/03/2018
Last updated
09/20/2018
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