Healthcare Provider Details

I. General information

NPI: 1154392223
Provider Name (Legal Business Name): NICOLE GAY INGRAM FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19250 SW 65TH AVE SUITE 300
TUALATIN OR
97062-7452
US

IV. Provider business mailing address

7405 SW BARBUR BLVD STE 250
PORTLAND OR
97219-2289
US

V. Phone/Fax

Practice location:
  • Phone: 503-855-1205
  • Fax:
Mailing address:
  • Phone: 503-919-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200550147
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: