Provider Demographics
NPI:1023882735
Name:WORTHINGTON, NICOLE ALEXIS (LMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXIS
Last Name:WORTHINGTON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8408 N BRANDON AVE UNIT 305
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-6884
Mailing Address - Country:US
Mailing Address - Phone:714-615-5412
Mailing Address - Fax:
Practice Address - Street 1:2262 N ALBINA AVE STE 131
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1793
Practice Address - Country:US
Practice Address - Phone:714-615-5412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27419225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist