Basic Information
| Provider Information | |||||||||
| NPI: | 1710944178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICOLETTI | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1508 DIVISION ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970451582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036571071 | ||||||||
| FaxNumber: | 5036573321 | ||||||||
| Practice Location | |||||||||
| Address1: | 1508 DIVISION ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | OREGON CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970451582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036571071 | ||||||||
| FaxNumber: | 5036573321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 10/31/2011 | ||||||||
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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 | 367A00000X | 088007215N5 NMNP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 124953 | 05 | OR | MEDICAID |