Healthcare Provider Details

I. General information

NPI: 1649500646
Provider Name (Legal Business Name): CAROLYN IACULLO NYGAARD N.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2010
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 W MARINE DR STE 103
ASTORIA OR
97103-5848
US

IV. Provider business mailing address

757 W MARINE DR STE 103
ASTORIA OR
97103-5848
US

V. Phone/Fax

Practice location:
  • Phone: 207-209-4858
  • Fax: 207-405-2199
Mailing address:
  • Phone: 207-209-4858
  • Fax: 207-405-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberND1546
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number1717
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License NumberNP839
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: