Provider Demographics
NPI:1548479298
Name:NAKAMURA, CORINNE
Entity type:Individual
Prefix:
First Name:CORINNE
Middle Name:
Last Name:NAKAMURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6124 NE HOYT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-4355
Mailing Address - Country:US
Mailing Address - Phone:617-270-1131
Mailing Address - Fax:
Practice Address - Street 1:6010 SW SHATTUCK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97221-1043
Practice Address - Country:US
Practice Address - Phone:617-270-1131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226521171100000X
OR03224225100000X
ORAC165202171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No171100000XOther Service ProvidersAcupuncturist