Provider Demographics
NPI:1992350854
Name:TABBAL, NICOLE C (AGACNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:C
Last Name:TABBAL
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25030 SW PARKWAY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9816
Mailing Address - Country:US
Mailing Address - Phone:971-434-0080
Mailing Address - Fax:503-946-3891
Practice Address - Street 1:25030 SW PARKWAY AVE STE 200
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9816
Practice Address - Country:US
Practice Address - Phone:971-434-0080
Practice Address - Fax:503-946-3891
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK201906846NP-PP363LG0600X
OR201906846NP-PP363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology