Healthcare Provider Details

I. General information

NPI: 1659778793
Provider Name (Legal Business Name): NICOLE CARTER MN, CNS, CMSRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3710 SW US VETERANS HOSPITAL RD
PORTLAND OR
97239-2964
US

IV. Provider business mailing address

1387 NE 17TH AVE
CANBY OR
97013-2365
US

V. Phone/Fax

Practice location:
  • Phone: 503-220-8262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number201407480
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: