Provider Demographics
NPI:1689023368
Name:SMITH, NICOLE (LPN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 PACIFIC AVE S STE C
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-1638
Mailing Address - Country:US
Mailing Address - Phone:360-425-5378
Mailing Address - Fax:360-425-5990
Practice Address - Street 1:6601 NE 78TH CT STE A3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97218-2823
Practice Address - Country:US
Practice Address - Phone:503-252-3949
Practice Address - Fax:503-252-4027
Is Sole Proprietor?:No
Enumeration Date:2016-06-03
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201130652LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse