Provider Demographics
NPI:1659564037
Name:LANEY, NICOLE LEE (PTA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:LANEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5022 SW SLAVIN RD APT 19
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2838
Mailing Address - Country:US
Mailing Address - Phone:503-704-3140
Mailing Address - Fax:
Practice Address - Street 1:10220 SW GREENBURG RD STE 201
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-5505
Practice Address - Country:US
Practice Address - Phone:503-570-3665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR8369225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant