Provider Demographics
NPI:1871769307
Name:BARNES, NICOLE (PT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BARNES
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:LYNNE
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:1520 W STATE ST
Practice Address - Street 2:STE 210
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4085
Practice Address - Country:US
Practice Address - Phone:208-336-8433
Practice Address - Fax:208-336-8441
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-1831225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0330319OtherWA L&I
ID1871769307Medicaid
ID16500951Medicare PIN