Provider Demographics
NPI:1407247927
Name:NICHOLSON, SYRENA (LMT)
Entity Type:Individual
Prefix:
First Name:SYRENA
Middle Name:
Last Name:NICHOLSON
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 1:7721 SE 92ND AVE
Mailing Address - Street 2:APT K
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-6227
Mailing Address - Country:US
Mailing Address - Phone:415-672-1319
Mailing Address - Fax:
Practice Address - Street 1:7721 SE 92ND AVENUE
Practice Address - Street 2:APT K
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266
Practice Address - Country:US
Practice Address - Phone:415-672-1319
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20848172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker