Provider Demographics
NPI:1811317928
Name:NUCKOLLS, KATHERYN (ND)
Entity type:Individual
Prefix:
First Name:KATHERYN
Middle Name:
Last Name:NUCKOLLS
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 1:9901 NE 86TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-2109
Mailing Address - Country:US
Mailing Address - Phone:602-359-2893
Mailing Address - Fax:
Practice Address - Street 1:650 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333
Practice Address - Country:US
Practice Address - Phone:541-602-0260
Practice Address - Fax:541-753-4217
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14-1424175F00000X
WA61288239175F00000X
OR4086175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath