Basic Information
| Provider Information | |||||||||
| NPI: | 1114044971 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | LEW | ||||||||
| FirstName: | NICHOLE | ||||||||
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| NamePrefix: | MRS. | ||||||||
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| Credential: | ATC - PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16521 NE 29TH ST | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986828673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609445208 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25117 SW PARKWAY AVE STE D | ||||||||
| Address2: | |||||||||
| City: | WILSONVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970709697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035703665 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2007 | ||||||||
| LastUpdateDate: | 06/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | P160334499 | WA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant | 2255A2300X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225200000X | 8244 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.