Provider Demographics
NPI:1962967042
Name:HERZOG, NICOLE LYNN
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:HERZOG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2145 CENTENNIAL PLZ
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-2474
Mailing Address - Country:US
Mailing Address - Phone:541-485-6340
Mailing Address - Fax:541-984-3124
Practice Address - Street 1:2145 CENTENNIAL PLZ
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-2474
Practice Address - Country:US
Practice Address - Phone:541-485-6340
Practice Address - Fax:541-984-3124
Is Sole Proprietor?:No
Enumeration Date:2019-02-04
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101YM0800XMedicaid