Provider Demographics
NPI:1518360148
Name:NELSON, HEIDI (LMP)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4102 DAYTON AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-7723
Mailing Address - Country:US
Mailing Address - Phone:206-718-4910
Mailing Address - Fax:
Practice Address - Street 1:5962 FAUNTLEROY WAY SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98136-1633
Practice Address - Country:US
Practice Address - Phone:206-420-7664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-26
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60503822225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist