Healthcare Provider Details

I. General information

NPI: 1114893609
Provider Name (Legal Business Name): NICOLE LEX FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 NW 5TH ST STE 101
REDMOND OR
97756-1869
US

IV. Provider business mailing address

20062 ELIZABETH LN
BEND OR
97702-2227
US

V. Phone/Fax

Practice location:
  • Phone: 541-526-6635
  • Fax: 541-526-6636
Mailing address:
  • Phone: 612-708-0723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10046588
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: