Provider Demographics
NPI:1063745453
Name:LANE, NICOLE (RN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LANE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 NE 16TH WAY
Mailing Address - Street 2:APT 308
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-4272
Mailing Address - Country:US
Mailing Address - Phone:503-492-4903
Mailing Address - Fax:
Practice Address - Street 1:1616 NE 16TH WAY
Practice Address - Street 2:APT 308
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-4272
Practice Address - Country:US
Practice Address - Phone:503-492-4903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2000940759RN163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine