Provider Demographics
NPI:1033540919
Name:HALVERSON, NICHOL SUZANNE (ARNP)
Entity Type:Individual
Prefix:
First Name:NICHOL
Middle Name:SUZANNE
Last Name:HALVERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 9TH AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2464
Mailing Address - Country:US
Mailing Address - Phone:360-501-3400
Mailing Address - Fax:360-423-5682
Practice Address - Street 1:625 9TH AVE STE 210
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2465
Practice Address - Country:US
Practice Address - Phone:360-501-3400
Practice Address - Fax:360-423-6862
Is Sole Proprietor?:No
Enumeration Date:2013-12-03
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP 60538584363LF0000X
WAAP60538584363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1033540919Medicaid
WA1033540919Medicaid