Provider Demographics
NPI:1417497439
Name:KILIAN, NICOLE (ND)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KILIAN
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:WILTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7730 SW 40TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1642
Mailing Address - Country:US
Mailing Address - Phone:503-333-1972
Mailing Address - Fax:
Practice Address - Street 1:2456 NW NORTHRUP ST
Practice Address - Street 2:SUITE 1A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3253
Practice Address - Country:US
Practice Address - Phone:503-223-7067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171100000X
OR4056175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist