Individual
KRISTEN ELAINE DERRY
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
12116 SE MILL PLAIN BLVD STE 1, VANCOUVER, WA 98684-6000
(360) 719-1512
(503) 254-0576
Mailing address
5105 SW ELM AVE, BEAVERTON, OR 97005-4230
(541) 659-9318
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
3579ATI
OR
152W00000X
Optometrist
Primary
60503088
WA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500740584
—
OR
Enumeration date
04/22/2013
Last updated
10/03/2022
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