Provider Demographics
NPI:1144518788
Name:DRAHUSCHAK, NICOLE FAYE (NP-C)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:FAYE
Last Name:DRAHUSCHAK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1253
Mailing Address - Fax:360-729-3185
Practice Address - Street 1:3377 RIVERBEND DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477
Practice Address - Country:US
Practice Address - Phone:541-222-6200
Practice Address - Fax:541-222-6182
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201901042NP-PP363L00000X
MSR895787363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP01403841OtherRAILROAD MEDICARE
MS04288876Medicaid
MSP01403841OtherRAILROAD MEDICARE