Healthcare Provider Details

I. General information

NPI: 1003045832
Provider Name (Legal Business Name): NICOLE MARIE GRANGER LMT, LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE MARIE ROBINSON LMT, LMP

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13712 NE 20TH AVE
VANCOUVER WA
98686-2698
US

IV. Provider business mailing address

9638 SW LARSON RD
GASTON OR
97119-7721
US

V. Phone/Fax

Practice location:
  • Phone: 360-574-5944
  • Fax:
Mailing address:
  • Phone: 503-998-0418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number15945
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: