Provider Demographics
NPI:1962864959
Name:DECKER-ST ONGE, NICHOLE LEE (MSN, CRNA, APRN)
Entity type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:LEE
Last Name:DECKER-ST ONGE
Suffix:
Gender:
Credentials:MSN, CRNA, APRN
Other - Prefix:MS
Other - First Name:NICHOLE
Other - Middle Name:LEE
Other - Last Name:DECKER-FARIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, BSN, SRNA
Mailing Address - Street 1:100 GANNETT DR STE C
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-5900
Mailing Address - Country:US
Mailing Address - Phone:207-828-0361
Mailing Address - Fax:207-874-1483
Practice Address - Street 1:84 MARGINAL WAY STE 1000
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2477
Practice Address - Country:US
Practice Address - Phone:207-347-2898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-28
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERNA173026367500000X
MER059846390200000X
MARN2301816390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered