Provider Demographics
NPI:1871569962
Name:LIEDEL, MARY R (CNM)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:R
Last Name:LIEDEL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N VANCOUVER AVE
Mailing Address - Street 2:SUITE 255
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1630
Mailing Address - Country:US
Mailing Address - Phone:503-413-4500
Mailing Address - Fax:
Practice Address - Street 1:2800 N VANCOUVER AVE
Practice Address - Street 2:SUITE 255
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1630
Practice Address - Country:US
Practice Address - Phone:503-413-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000034705367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR263418Medicaid
ORR85953Medicare UPIN
OR130259Medicare ID - Type Unspecified