Provider Demographics
NPI:1447503107
Name:CAROL NIGHTENGALE P C
Entity type:Organization
Organization Name:CAROL NIGHTENGALE P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:NIGHTENGALE
Authorized Official - Suffix:
Authorized Official - Credentials:PC
Authorized Official - Phone:503-669-1095
Mailing Address - Street 1:PO BOX 1503
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-1506
Mailing Address - Country:US
Mailing Address - Phone:503-669-1095
Mailing Address - Fax:503-665-3299
Practice Address - Street 1:28467 SE K W ANDERSON RD
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97080-0016
Practice Address - Country:US
Practice Address - Phone:503-669-1095
Practice Address - Fax:503-665-3299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR592305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR108585Medicare PIN