Provider Demographics
NPI:1487311163
Name:NIXON, LAURIE N (LMT)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:N
Last Name:NIXON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 SE WOODWARD ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-2257
Mailing Address - Country:US
Mailing Address - Phone:206-458-2042
Mailing Address - Fax:
Practice Address - Street 1:3241 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1814
Practice Address - Country:US
Practice Address - Phone:503-282-8582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR26145225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist