Healthcare Provider Details

I. General information

NPI: 1407285885
Provider Name (Legal Business Name): NICOLE GILCHRIST LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37067 S WILHOIT RD
MOLALLA OR
97038-9742
US

IV. Provider business mailing address

37067 S WILHOIT RD
MOLALLA OR
97038-9742
US

V. Phone/Fax

Practice location:
  • Phone: 808-499-9360
  • Fax:
Mailing address:
  • Phone: 808-499-9360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number19904
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: