Provider Demographics
NPI:1922569748
Name:FENNIMORE, NICOLE JENE (MD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:JENE
Last Name:FENNIMORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 SE MAIN ST STE 3001
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2458
Mailing Address - Country:US
Mailing Address - Phone:503-261-4423
Mailing Address - Fax:
Practice Address - Street 1:10101 SE MAIN ST STE 3001
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2458
Practice Address - Country:US
Practice Address - Phone:503-261-4423
Practice Address - Fax:503-261-4424
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD205498207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology