Provider Demographics
NPI:1811368053
Name:BORT, NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BORT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26908 DETROIT RD STE 103
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2399
Mailing Address - Country:US
Mailing Address - Phone:440-249-0274
Mailing Address - Fax:440-808-5969
Practice Address - Street 1:4065 CENTER RD STE 214
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-5325
Practice Address - Country:US
Practice Address - Phone:216-286-2253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-14
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.18014NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCOA.18014NPOtherSTATE LICENSE