Provider Demographics
NPI:1376178608
Name:NIELSON, KIAH (OTR/L)
Entity Type:Individual
Prefix:
First Name:KIAH
Middle Name:
Last Name:NIELSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:KIAH
Other - Middle Name:
Other - Last Name:VANASSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1702 E MAIN ST STE 103
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-3818
Mailing Address - Country:US
Mailing Address - Phone:701-415-0000
Mailing Address - Fax:833-969-0195
Practice Address - Street 1:1702 E MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-3818
Practice Address - Country:US
Practice Address - Phone:701-415-0000
Practice Address - Fax:833-969-0195
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1769225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1480347Medicaid