Provider Demographics
NPI:1962671412
Name:ROGERS, NICKI LYNN (NP)
Entity Type:Individual
Prefix:
First Name:NICKI
Middle Name:LYNN
Last Name:ROGERS
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 1:7650 SW BEVELAND RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8692
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7431 NW EVERGREEN PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:HILLSBORO
Practice Address - State:OR
Practice Address - Zip Code:97124-5831
Practice Address - Country:US
Practice Address - Phone:503-734-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-28
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA546766364S00000X
OR201408658NP-PP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA546766OtherMEDICAL LICENSE
OR500704873Medicaid