=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407400500
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE BENTHIN NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/26/2019
-----------------------------------------------------
Last Update Date | 09/25/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 S WAHANNA RD STE 230
-----------------------------------------------------
City | SEASIDE
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97138-7735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-741-7060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 783
-----------------------------------------------------
City | ASTORIA
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97103-0783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-791-4156
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 201905533NP-PP
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------