MEDICARE: NICOLE ELLEDGE OTR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	1060547	OR

General Provider Information

NPI Number	:	1003075417
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE ELLEDGE OTR

Provider Business Mailing Address
First Line	:	23532 SW STONEHAVEN ST
Second Line	:
City	:	SHERWOOD
State	:	OR
Zip	:	97140-7076
Country	:	US
Telephone Number	:	971-732-2991
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 KRUSE WAY PL
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-2512
Country	:	US
Telephone Number	:	503-607-0566
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2008
Last Update Date	:	05/06/2022

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