Provider Demographics
NPI:1891929923
Name:WILSON, NICOLE MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:STILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:1411 NW RALEIGH STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-2573
Mailing Address - Country:US
Mailing Address - Phone:503-803-2208
Mailing Address - Fax:
Practice Address - Street 1:1411 NW RALEIGH STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-2573
Practice Address - Country:US
Practice Address - Phone:503-803-2208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-04
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3914111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor