1023249125 NPI number — CAROLYN KYLE NIXON

Table of content: CAROLYN KYLE NIXON (NPI 1023249125)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023249125 NPI number — CAROLYN KYLE NIXON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIXON
Provider First Name:
CAROLYN
Provider Middle Name:
KYLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SIDLES
Provider Other First Name:
CAROLYN
Provider Other Middle Name:
KYLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023249125
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3181 SW SAM JACKSON PARK RD.
Provider Second Line Business Mailing Address:
MAIL CODE SJH-2
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97239-3011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-494-7551
Provider Business Mailing Address Fax Number:
503-494-4997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3181 SW SAM JACKSON PARK RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97239-3011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-494-7551
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/06/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA170105 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA170105 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 500679615 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".