Healthcare Provider Details

I. General information

NPI: 1144518788
Provider Name (Legal Business Name): NICOLE FAYE DRAHUSCHAK NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2011
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3377 RIVERBEND DR
SPRINGFIELD OR
97477
US

IV. Provider business mailing address

1115 SE 164TH AVE DEPT 358
VANCOUVER WA
98683-8004
US

V. Phone/Fax

Practice location:
  • Phone: 541-222-6200
  • Fax: 541-222-6182
Mailing address:
  • Phone: 360-729-1253
  • Fax: 360-729-3185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201901042NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR895787
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: