Provider Demographics
NPI:1104826601
Name:MCDANIEL, NICOLE MARIE (PT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICKI
Other - Middle Name:
Other - Last Name:MCDANIEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:530 NW 23RD AVE
Mailing Address - Street 2:SUITE #116
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3287
Mailing Address - Country:US
Mailing Address - Phone:971-258-0995
Mailing Address - Fax:844-364-4344
Practice Address - Street 1:530 NW 23RD AVE
Practice Address - Street 2:SUITE #116
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3275
Practice Address - Country:US
Practice Address - Phone:971-258-0995
Practice Address - Fax:844-364-4344
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5138174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM17657385Medicaid
NM2914OtherSTATE OF NM REG & LICENS.