Provider Demographics
NPI:1295934750
Name:CHRISTIANSEN, NICOLE DIDENTI (MD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:DIDENTI
Last Name:CHRISTIANSEN
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 1:2250 NW FLANDERS ST
Mailing Address - Street 2:#306
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-3443
Mailing Address - Country:US
Mailing Address - Phone:503-276-1290
Mailing Address - Fax:503-343-6261
Practice Address - Street 1:2250 NW FLANDERS ST
Practice Address - Street 2:#306
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3443
Practice Address - Country:US
Practice Address - Phone:503-226-0558
Practice Address - Fax:503-276-1284
Is Sole Proprietor?:No
Enumeration Date:2007-07-15
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD162095207R00000X, 2084P0800X, 2084P0804X
MA2331582084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500655795Medicaid
OR500655896Medicaid
ORR169142Medicare PIN