Healthcare Provider Details

I. General information

NPI: 1376276899
Provider Name (Legal Business Name): NICOLE RENEE STICKA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 W. 7TH AVE.
EUGENE OR
97401
US

IV. Provider business mailing address

2605 JUSTINE LN
EUGENE OR
97404
US

V. Phone/Fax

Practice location:
  • Phone: 541-682-4041
  • Fax:
Mailing address:
  • Phone: 307-331-0294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number21945
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: