Provider Demographics
NPI:1760001648
Name:COWART, NICOLE MARIE (CFM)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:COWART
Suffix:
Gender:F
Credentials:CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-0746
Mailing Address - Country:US
Mailing Address - Phone:541-370-5640
Mailing Address - Fax:
Practice Address - Street 1:500 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2217
Practice Address - Country:US
Practice Address - Phone:541-370-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DECFM01332224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter