Healthcare Provider Details

I. General information

NPI: 1124371059
Provider Name (Legal Business Name): NICKOLE TURNER LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2012
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2831 SE PALMQUIST RD #157
GRESHAM OR
97080
US

IV. Provider business mailing address

PO BOX 876
FAIRVIEW OR
97024
US

V. Phone/Fax

Practice location:
  • Phone: 503-490-5986
  • Fax:
Mailing address:
  • Phone: 503-490-5986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number18561
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: