Provider Demographics
NPI:1225437734
Name:ANSLOW, NELLYDA (NP)
Entity Type:Individual
Prefix:
First Name:NELLYDA
Middle Name:
Last Name:ANSLOW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 NW ELKS DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3745
Mailing Address - Country:US
Mailing Address - Phone:541-754-1150
Mailing Address - Fax:
Practice Address - Street 1:3680 NW SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3737
Practice Address - Country:US
Practice Address - Phone:541-754-1150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-20
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201408083NP-PP363LA2200X, 363LG0600X
OR200641338RN363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5451211OtherOR DRIVERS LICENSE
OR5451211OtherOR DRIVERS LICENSE
OR93-0635514OtherGROUP TAX ID NORTH BEND MEDICAL CENTER
OR161133OtherGROUP MEDICAID NORTH BEND MEDICAL CENTER
ORR0000WFBTVOtherGROUP MEDICARE NORTH BEND MEDICAL CENTER