Individual
TINA MARIE CONKLIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
3099 NE DIAMOND LAKE BLVD, ROSEBURG, OR 97470-3655
(541) 673-3469
Mailing address
PO BOX 1121, ROSEBURG, OR 97470-0254
(541) 672-2691
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
200330020LPN
OR
171M00000X
Case Manager/Care Coordinator
21-QMHA-R-1339
OR
Other
Enumeration date
07/22/2021
Last updated
07/31/2023
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