Individual
EDLAWET G FANTA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
10244 SE RAYMOND ST, PORTLAND, OR 97266-3636
(971) 320-9189
Mailing address
10244 SE RAYMOND ST, PORTLAND, OR 97266-3636
(971) 320-9189
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
10029602
OR
Other
Enumeration date
05/06/2026
Last updated
05/06/2026
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