Provider Demographics
NPI:1093033219
Name:CULLEN, NICOLE LOUISE (BS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LOUISE
Last Name:CULLEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 EAGLE CREST DR APT 5C
Mailing Address - Street 2:
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-1068
Mailing Address - Country:US
Mailing Address - Phone:520-400-6798
Mailing Address - Fax:
Practice Address - Street 1:3737 PORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0311
Practice Address - Country:US
Practice Address - Phone:503-390-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR930903773Medicaid