MEDICARE: OCTAVIA M NIGHTINGALE

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	3140N1450X	Pediatric Skilled Nursing Facility	513068	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1225639826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OCTAVIA M NIGHTINGALE

Provider Business Mailing Address
First Line	:	4190 COLLINS WAY
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-3448
Country	:	US
Telephone Number	:	503-636-0966
Fax Number	:	503-675-3552

Provider Business Practice Location Address
First Line	:	4190 COLLINS WAY
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-3448
Country	:	US
Telephone Number	:	503-636-0966
Fax Number	:	503-675-3552

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

Provider Enumeration Date	:	11/02/2020
Last Update Date	:	11/02/2020

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Directions to “ OCTAVIA M NIGHTINGALE ” Practice Location

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