Healthcare Provider Details

I. General information

NPI: 1801337746
Provider Name (Legal Business Name): NIKKIEL KING MSN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NIKKIEL LEFEBRE NIKKIEL LEFEBRE

II. Dates (important events)

Enumeration Date: 03/11/2017
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 NE ROBERTS AVE
GRESHAM OR
97030-7307
US

IV. Provider business mailing address

515 NE ROBERTS AVE
GRESHAM OR
97030-7307
US

V. Phone/Fax

Practice location:
  • Phone: 503-477-2477
  • Fax: 423-205-3302
Mailing address:
  • Phone: 503-894-0493
  • Fax: 423-205-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201701614NP-PP
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: