Provider Demographics
NPI:1558548370
Name:DESIDERATI, NICOLE MARIE (RN PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MARIE
Last Name:DESIDERATI
Suffix:
Gender:F
Credentials:RN PMHNP-BC
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Mailing Address - Street 1:PO BOX 16308
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0308
Mailing Address - Country:US
Mailing Address - Phone:503-255-2343
Mailing Address - Fax:503-255-2344
Practice Address - Street 1:10011 SE DIVISION ST
Practice Address - Street 2:SUITE 203
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1351
Practice Address - Country:US
Practice Address - Phone:503-255-2343
Practice Address - Fax:503-255-2344
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2014-12-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OR201350103NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR22959Medicaid
ORR0000WCJHTMedicare Oscar/Certification