Provider Demographics
NPI:1629423967
Name:BENTLEY, NICOLE LEE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:BENTLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LEE
Other - Last Name:GOODALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5100 PRAIRIE PKWY STE 203
Mailing Address - Street 2:
Mailing Address - City:CEDAR FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50613-8155
Mailing Address - Country:US
Mailing Address - Phone:319-222-2903
Mailing Address - Fax:319-222-2993
Practice Address - Street 1:5100 PRAIRIE PKWY STE 203
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50613
Practice Address - Country:US
Practice Address - Phone:319-222-2903
Practice Address - Fax:319-222-2993
Is Sole Proprietor?:No
Enumeration Date:2016-04-24
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI68391-20208000000X
IAMD-46258208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics