Provider Demographics
NPI:1164654166
Name:BENNETT, NICOLE MACKENZIE (PMHNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MACKENZIE
Last Name:BENNETT
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 NE MULTNOMAH ST
Mailing Address - Street 2:SUITE 275
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2131
Mailing Address - Country:US
Mailing Address - Phone:503-729-1380
Mailing Address - Fax:503-841-6343
Practice Address - Street 1:700 NE MULTNOMAH ST
Practice Address - Street 2:SUITE 275
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-2131
Practice Address - Country:US
Practice Address - Phone:503-729-1380
Practice Address - Fax:503-841-6343
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200950088NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health