Provider Demographics
NPI:1366680993
Name:NANIE, JENNIFER LYNNE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNNE
Last Name:NANIE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 TREVITT ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-1463
Mailing Address - Country:US
Mailing Address - Phone:541-296-6495
Mailing Address - Fax:541-296-6497
Practice Address - Street 1:1012 TREVITT ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-1463
Practice Address - Country:US
Practice Address - Phone:541-296-6495
Practice Address - Fax:541-296-6497
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14616174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist