Provider Demographics
NPI:1093729873
Name:NELSEN, MICHELE K (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:K
Last Name:NELSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:STE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-4970
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:14410 SE PETROVITSKY RD STE 104
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98058-8900
Practice Address - Country:US
Practice Address - Phone:256-903-4054
Practice Address - Fax:425-690-9405
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035357207VX0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1042822Medicaid
WAG8891361OtherMEDICARE W VALLEY MEDICAL GROUP - RENTON
WAGAB36072Medicare PIN