Basic Information
| Provider Information | |||||||||
| NPI: | 1558548370 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESIDERATI | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16308 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972920308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032552343 | ||||||||
| FaxNumber: | 5032552344 | ||||||||
| Practice Location | |||||||||
| Address1: | 10011 SE DIVISION ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972661351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032552343 | ||||||||
| FaxNumber: | 5032552344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2008 | ||||||||
| LastUpdateDate: | 12/17/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 201350103NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 096511 | 05 | OR | MEDICAID | 22959 | 05 | OR | MEDICAID |