Provider Demographics
NPI:1083653208
Name:NELSON, DWIGHT L (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:L
Last Name:NELSON
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 NW 119TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-3714
Mailing Address - Country:US
Mailing Address - Phone:360-574-7883
Mailing Address - Fax:
Practice Address - Street 1:10411 NE FOURTH PLAIN RD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6303
Practice Address - Country:US
Practice Address - Phone:360-882-1489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2042237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9052259Medicaid