Healthcare Provider Details

I. General information

NPI: 1629423967
Provider Name (Legal Business Name): NICOLE LEE BENTLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE LEE GOODALE

II. Dates (important events)

Enumeration Date: 04/24/2016
Last Update Date: 06/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 PRAIRIE PKWY STE 203
CEDAR FALLS IA
50613
US

IV. Provider business mailing address

5100 PRAIRIE PKWY STE 203
CEDAR FALLS IA
50613-8155
US

V. Phone/Fax

Practice location:
  • Phone: 319-222-2903
  • Fax: 319-222-2993
Mailing address:
  • Phone: 319-222-2903
  • Fax: 319-222-2993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number68391-20
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD-46258
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: