Healthcare Provider Details

I. General information

NPI: 1205010170
Provider Name (Legal Business Name): KATIE NICOSIA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 03/06/2020
Certification Date: 03/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 N VILLA RD
NEWBERG OR
97132-1858
US

IV. Provider business mailing address

470 N VILLA RD
NEWBERG OR
97132-1858
US

V. Phone/Fax

Practice location:
  • Phone: 503-406-1009
  • Fax: 503-200-2975
Mailing address:
  • Phone: 503-406-1009
  • Fax: 503-200-2975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200750105NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: