Provider Demographics
NPI:1043047095
Name:GUERRA WILLINGHAM, NICOLE (LMT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GUERRA WILLINGHAM
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 1:1238 SW SILVER LAKE BLVD
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-2236
Mailing Address - Country:US
Mailing Address - Phone:458-600-3249
Mailing Address - Fax:
Practice Address - Street 1:424 NE FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-4919
Practice Address - Country:US
Practice Address - Phone:541-388-3588
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27761225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist