Provider Demographics
NPI:1205010170
Name:NICOSIA, KATIE (FNP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:NICOSIA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 N VILLA RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-1858
Mailing Address - Country:US
Mailing Address - Phone:503-406-1009
Mailing Address - Fax:503-200-2975
Practice Address - Street 1:470 N VILLA RD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-1858
Practice Address - Country:US
Practice Address - Phone:503-406-1009
Practice Address - Fax:503-200-2975
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200750105NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily