Provider Demographics
NPI:1760036453
Name:GANSEMER, NICOLE (ND)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GANSEMER
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 NE 7TH AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3998
Mailing Address - Country:US
Mailing Address - Phone:503-282-1070
Mailing Address - Fax:
Practice Address - Street 1:2612 E BARNETT RD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8344
Practice Address - Country:US
Practice Address - Phone:541-770-5563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath