Provider Demographics
NPI:1003045832
Name:GRANGER, NICOLE MARIE (LMT, LMP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:GRANGER
Suffix:
Gender:F
Credentials:LMT, LMP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT, LMP
Mailing Address - Street 1:9638 SW LARSON RD
Mailing Address - Street 2:
Mailing Address - City:GASTON
Mailing Address - State:OR
Mailing Address - Zip Code:97119-7721
Mailing Address - Country:US
Mailing Address - Phone:503-998-0418
Mailing Address - Fax:
Practice Address - Street 1:13712 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2698
Practice Address - Country:US
Practice Address - Phone:360-574-5944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15945111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor