Provider Demographics
NPI:1235553801
Name:NICHOLSON, PEGGY ELOISE (RN, NP-C)
Entity Type:Individual
Prefix:MS
First Name:PEGGY
Middle Name:ELOISE
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:RN, NP-C
Other - Prefix:
Other - First Name:PEGGY
Other - Middle Name:ELOISE
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1253
Mailing Address - Fax:360-729-3185
Practice Address - Street 1:1200 HILYARD ST STE 450
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8164
Practice Address - Country:US
Practice Address - Phone:458-205-7131
Practice Address - Fax:541-687-6214
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201804601NP-PP363L00000X
NVAPRN002061363L00000X
NMCNP-02348363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1235553801Medicaid