Provider Demographics
NPI:1295192540
Name:AVILA-PARKER, NICOLE (PMHNP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:AVILA-PARKER
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S COOLIDGE ST
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837-1872
Mailing Address - Country:US
Mailing Address - Phone:509-493-9715
Mailing Address - Fax:
Practice Address - Street 1:1550 S PIONEER WAY STE 165
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-4637
Practice Address - Country:US
Practice Address - Phone:509-793-9780
Practice Address - Fax:509-764-3244
Is Sole Proprietor?:No
Enumeration Date:2016-01-18
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60633381363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8985877OtherMEDICARE PIN
WAP01626675OtherRR MEDICARE WVH
WA1295192540Medicaid
WA2056200Medicaid