Provider Demographics
NPI:1407041379
Name:CANALE, NICOLE ALEXIS (MPT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ALEXIS
Last Name:CANALE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3912 NE 68TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-5121
Mailing Address - Country:US
Mailing Address - Phone:503-525-1204
Mailing Address - Fax:
Practice Address - Street 1:3912 NE 68TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-5121
Practice Address - Country:US
Practice Address - Phone:503-525-1204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4721225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist