Provider Demographics
NPI:1649500646
Name:NYGAARD, CAROLYN IACULLO (ND)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:IACULLO
Last Name:NYGAARD
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 COMMERCIAL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3800
Mailing Address - Country:US
Mailing Address - Phone:503-741-3636
Mailing Address - Fax:503-741-3446
Practice Address - Street 1:1490 COMMERCIAL ST STE 200
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3800
Practice Address - Country:US
Practice Address - Phone:503-741-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-13
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1717207Q00000X, 175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500642404Medicaid