Basic Information
| Provider Information | |||||||||
| NPI: | 1114554037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOTTESINI | ||||||||
| FirstName: | NICOLETTE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 NW 23RD AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972102906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034137074 | ||||||||
| FaxNumber: | 5034136892 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 NW 23RD AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972102906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034137074 | ||||||||
| FaxNumber: | 5034136892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2020 | ||||||||
| LastUpdateDate: | 06/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.