Provider Demographics
NPI:1194041020
Name:WILSON, NELLIE (LMT, LMP)
Entity Type:Individual
Prefix:MRS
First Name:NELLIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LMT, LMP
Other - Prefix:
Other - First Name:NELLIE
Other - Middle Name:
Other - Last Name:GRIESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1301 SW SWANTOWN AVE
Mailing Address - Street 2:APT #4
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-7184
Mailing Address - Country:US
Mailing Address - Phone:503-936-2061
Mailing Address - Fax:503-296-2447
Practice Address - Street 1:520 E WHIDBEY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5922
Practice Address - Country:US
Practice Address - Phone:503-936-2061
Practice Address - Fax:503-296-2447
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-16
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60349569225700000X
OR16594225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist