Provider Demographics
NPI:1114608866
Name:PENLEY, NICOLETTE MARIE (LMT, CA)
Entity type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:MARIE
Last Name:PENLEY
Suffix:
Gender:F
Credentials:LMT, CA
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:MARIE
Other - Last Name:PENLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1611 NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-3328
Mailing Address - Country:US
Mailing Address - Phone:775-843-0220
Mailing Address - Fax:
Practice Address - Street 1:100 E 2ND ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-1704
Practice Address - Country:US
Practice Address - Phone:541-900-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27740225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist