Healthcare Provider Details

I. General information

NPI: 1114306743
Provider Name (Legal Business Name): NANCY MARIE CARLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 05/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14090 SW TEAL BLVD A17
BEAVERTON OR
97008-9210
US

IV. Provider business mailing address

14090 SW TEAL BLVD A17
BEAVERTON OR
97008-9210
US

V. Phone/Fax

Practice location:
  • Phone: 503-888-1666
  • Fax:
Mailing address:
  • Phone: 503-888-1666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number200140045RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: