Provider Demographics
NPI:1073689980
Name:NIELSON, KATHLEEN DIANE (LICENSED MASSAGE PRA)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:DIANE
Last Name:NIELSON
Suffix:
Gender:F
Credentials:LICENSED MASSAGE PRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20200 37TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1657
Mailing Address - Country:US
Mailing Address - Phone:206-365-2350
Mailing Address - Fax:
Practice Address - Street 1:20200 37TH AVE NE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-1657
Practice Address - Country:US
Practice Address - Phone:206-365-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA5015225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA63212OtherLABOR & INDUSTRIES
5829693OtherAETNA USHC
NI6014OtherREGENCE BLUE SHIELD