Provider Demographics
NPI:1710944178
Name:NICOLETTI, STEPHANIE J (CNM)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:J
Last Name:NICOLETTI
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 DIVISION ST
Mailing Address - Street 2:SUITE 205
Mailing Address - City:OREGON CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97045-1582
Mailing Address - Country:US
Mailing Address - Phone:503-657-1071
Mailing Address - Fax:503-657-3321
Practice Address - Street 1:1508 DIVISION ST
Practice Address - Street 2:SUITE 205
Practice Address - City:OREGON CITY
Practice Address - State:OR
Practice Address - Zip Code:97045-1582
Practice Address - Country:US
Practice Address - Phone:503-657-1071
Practice Address - Fax:503-657-3321
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR088007215N5 NMNP367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR124953Medicaid
OR124953Medicaid